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eligibility
 
The following forms may be printed from your personal computer and sent to the Plan Office via a postal service. All forms are valid only when both the Social Security number and signature of the Participant are provided.


Please submit all completed forms for processing to:
Eligibility Department--Confidential
MPI Health Plan
P.O. 1999
Studio City, CA 91614-0999


Our forms are in PDF (Portable Document Format). To read and print the PDF forms, you need the free Adobe Acrobat Reader, which may already be installed in your system.
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Active - Full-time Student Certification Form, Retiree - Full-time Student Certification Form - If your unmarried child is dependent upon you for primary support and is a full-time student in a fully accredited school or college, your child may be eligible for medical, hospital, prescription, vision and dental benefits through the Motion Picture Industry Health Plans. Complete this form if your eligible dependent child is a full-time student up to age 23.
Affidavit of Dependency for Tax purposes - This form must be completed when a Participant is enrolling their same-sex domestic partner to the Plan and is claiming their same-sex Domestic Partner as Dependent for “TAX” purposes. This form must be signed by both the Participant and the Domestic Partner and it must be notarized. This form is in addition to the Affidavit of Domestic Partnership form.
Affidavit of Domestic Partnership - This form is required for all Participants enrolling their same-sex domestic partners to the Plan. This form must be signed by both the Participant and the Domestic partner and it must be notarized.
Audit & Collections Department Participant Service Form - Participants complete this form if they believe there are errors in the Plans' record of their work history. Please note that sufficient supporting documentation is needed in order to initiate an investigation. Once you have gathered the necessary information/documentation, please send copies via US Postal Service to the attention of the Audit & Collections Department.
Change of Address - To ensure that you receive correspondence sent from the Plan, it is important that you notify the Eligibility Department immediately of any change in your mailing address.
 
Coordination of Benefits: Spouse's Requirements Under the Anthem Blue Cross Plan-Instructions - Please read this 2-page letter to determine which forms to complete.
Coordination of Benefits "Form 1" Questionnaire - Participants must complete and submit this "Form 1" in order to establish health eligibility for their spouse or same-sex domestic partner with the MPI Health Plan.
Coordination of Benefits "Form 2" Questionnaire - The spouse's/same-sex domestic partner's employer completes this "Form 2" certifying to their health insurance status.
Coordination of Benefits "Form 3" Declaration - Participants' spouses or same-sex domestic partners who are retired, unemployed, self-employed, or freelance and have no group health plan may remain covered by the MPIHP, but must fully complete, sign and submit this Coordination of Benefits Declaration and "Form 1" above.
Coordination of Benefits "Form 4" Confirmation - Participant's spouse/same-sex domestic partner must complete this confirmation of employer group health plan enrollment. Also indicates coverage provided for children under employer group health plan.

If you previously notified the MPI Health Plan of possible future enrollment in your employer's group health plan, this form must be completed and returned to the MPIHP Office upon actual enrollment in that plan.

If the MPI Health Plan determines that the spouse was eligible for health benefits through their employer but did not enroll, the MPI Health Plan will not provide any coverage for the spouse.
Coordination of Benefits: Non-Biological Child Form - Participants who have non-biological children, are not married to the parent of their biological children, have biological children who are covered under another policy as ordered by a court, or are divorced or are divorcing the parent of their biological children must complete this form to allow MPI to determine the order of payments for their dependent children.
 
COBRA Self-Pay Rates
Health Plan Beneficiary Card - Upon qualification for Initial Eligibility, you must complete a Beneficiary/Enrollment card to enroll your Eligible dependents (children, spouse, same-sex domestic partners, etc) and designate the beneficiary(ies) of your life insurance.
Medical/Dental Plan selection option - You only need to complete this form if:
  • You are initially or newly eligible or;
  • You wish to change the medical/hospital and/or the dental plan in which you are currently enrolled. (please be aware enrollment in the HMO plans for both Medical/Hospital and Dental, is only during July)
Requirements for Adding Dependents to your Health Insurance, and Application for Coverage-Non-Biological Dependent Child - This is the chart that spells out what documents are required in order to add your dependent(s) to your health insurance. Also included is the form required for adding a non-biological child to your health insurance.

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