Sponsor's Full Name
Type of Coverage
Select One Full Partial Limited
Type of Custody
Select One Full Shared
Parent's Full Name
Parent's Address 1
Parent's Address 2
Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia U.S. Virgin Islands Washington West Virginia Wisconsin Wyoming
Parent's ZIP Code
Please note the following:
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The above referenced sponsor acknowledges that he/she has
dental coverage through United Concordia Companies, Inc. The
group name and sponsor identification numbers have been
accurately set forth above.
The sponsor hereby acknowledges that he/she and the above
named custodial parent are divorced/separated and that he/she is
required to provide health care coverage for the above named
family member child pursuant to a valid court issued support
By way of this agreement, the sponsor directs the plans
henceforth to communicate directly with the above named
custodial parent regarding claims processed on the behalf of the
above named family member.
The sponsor acknowledges that because he/she has directed
the plans to communicate directly with the custodial parent
regarding payment of claims and to pay claims directly to the
custodial parent and because of the confidential nature of
medical records and information, that the plans are not
obligated to provide any information to the sponsor regarding
the payment of claims incurred by the eligible family member.
Both the sponsor and the custodial parent acknowledge that
this release shall remain in effect until withdrawn by the
Withdrawal of this release shall be made in writing on the
form provided by the plans and the sponsor shall provide the
custodial parent with written notice of the withdrawal of this
release at the same time that notice is provided to the plans.
The sponsor hereby releases and discharges the plans from
any and all claims, causes of action, damages and/or liability,
arising out of the plan’s communication or payment of claims on
behalf of the family member directly to the custodial parent.
The custodial parent hereby acknowledges that failure to
provide the plans with a correct mailing address or failure to
inform the plans of a change in address may result in claims
being improperly processed. The custodial parent hereby releases
and discharges the plans from any and all claims, causes of
action, damages and/or liability arising out of the plans’
misdirection of claims information or claims payments if such
was the result of misinformation or insufficient information
obtained from the custodial parent.
Authorized signature of member or personal representative *
Signature Date: 12/03/2022
Sponsor's Signature *
Signature Date: 12/03/2022
* I acknowledge and agree that by selecting this box I am
electronically signing this document and intend for it to be my legal
signature. I represent that I am authorized to sign this document and
that all information provided is correct to the best of my knowledge.
To allow the non-custodial parent to receive information
on the dependent child/children indicated on this form, complete
the HIPAA Privacy Release Form.