Health Plan Dependent Audit

A | A | A

Do not complete this form if you wish to change who you cover in your health plan next year. Instead, submit a medical change form posted at www.stlouiscountymn.gov/benefits.

Submit this form for each dependent you wish to continue to cover under your health plan next year.
Dependent's Name as it appears on medical card

First Name
Last Name
Dependent's First Name as it appears on medical card
Dependent's Last Name as it appears on medical card
Health Plan ID number (just numbers no letters) Hint: All family members have the same number as you.
Dependent Type
Birthdate (Don't estimate or guess)
Month - Day - Year
Captcha

Resources