Dependent Eligibility Requirements


  • Return this information ONLY if you are adding a new dependent on your Medical, Dental or Vision Coverage.

  • Listed below are the acceptable forms of documentation required for each dependent type to verify their eligibility to join CCMSI's plans.

  • Original documents are not required - copies are acceptable.

  • You are not required to provide financial information or your Social Security Number on any submitted documentation and this data should be concealed.

Dependent Type Primary Documentation Or Secondary Documentation
Spouse 2013 Federal or State tax return listing your spouse as a dependent(financial information and Social Security Number concealed);must be signed
  1. If taxes separately, a copy of spouse's 2013 tax return
  2. 2014 Utility bill or bank statement showing joint ownership and a certified(courthouse document) copy of marriage certificate
Natural/Adopted Child 2013 Federal or State tax return showing your child as a dependent(financial information and Social Security Number concealed);must be signed
  1. If on your spouse's tax return, a copy of their 2013 tax return
  2. Certified Birth Certificate or Adoption (courthouse document)
  3. Qualified Medical Child Support Order or the section of your divorce decree outlining your responsibility to cover your child
Step Child 2013 Federal or State tax return showing the child as a dependent(financial information and Social Security Number concealed);must be signed
  1. Certified Birth Certificate(courthouse document) and one of the following:
  1. Section of your spouse's divorce decree outlining joint custody
  2. Death certificate for natural parent