Adult Dependent Clause Samples

Adult Dependent. Permission to Disclose to: Permission to Disclose to: (Please use separate form for additional Adult Dependents) Permission to Disclose to: *Federal law prohibits disclosure of certain information of an individual without that individual's permission. This includes such things as: address, telephone number, date of birth, date of service, as defined in the regulations as Protected Health Information. Please read the instructions below before completing the Member Advance Agreement form. The information you provide will be used to fulfill your request to disclose your and, if applicable, your minor dependent(s)’ Protected Health Information (PHI) and identify the individual(s) who are involved in your health care or payment for health care, who will be permitted to receive your PHI. All required information must be completed in order for this request to be processed. If required information is not completed, your and, if applicable, your minor dependent(s)’ PHI will not be disclosed.
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Adult Dependent. This is to be filled in if any adult dependent on the policy is requesting Protected Health Information to be released.
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Related to Adult Dependent

  • Dependent for the purpose of this Agreement, dependent means a spouse, whether of the same or opposite gender, and children under eighteen (18) years of age, or twenty-four (24) years of age if the child is in full time attendance at a school or post-secondary institution or any child that remains in the direct care of the parent in the same household because the dependent is medically verified as disabled and under twenty-four (24) years of age.

  • Outpatient Dental Anesthesia Services This plan covers anesthesia services received in connection with a dental service when provided in a hospital or freestanding ambulatory surgical center and: • the use of this is medically necessary; and • the setting in which the service is received is determined to be appropriate. This plan also covers facility fees associated with these services. This plan covers dental care for members until the last day of the month in which they turn nineteen (19). This plan covers services only if they meet all of the following requirements: • listed as a covered dental care service in this section. The fact that a provider has prescribed or recommended a service, or that it is the only available treatment for an illness or injury does not mean it is a covered dental care service under this plan. • dentally necessary, consistent with our dental policies and related guidelines at the time the services are provided. • not listed in Exclusions section. • received while a member is enrolled in the plan. • consistent with applicable state or federal law. • services are provided by a network provider.

  • Dependent Child If dependent children are covered under separate plans of more than one person, whether a parent or guardian, benefits for the child will be determined in the following order: • the benefits of the plan covering the parent born earlier in the year will be determined before those of the parent whose birthday (month and day only) falls later in the year; • if both parents have the same birthday, the benefits of the plan that covered the parent longer are determined before those of the plan which covered the other parent for a shorter period of time; • if the other plan does not determine benefits according to the parents' birth dates, but by parents' gender instead, the other plan’s gender rule will determine the order of benefits.

  • Dependent Care The College will make available to employees, at their option, an Internal Revenue Service Code Section 129 Dependent Care plan. The plan will be established, administered, and communicated to employees by the State without cost to the employees.

  • Non-dependent Dependent