There isn't a PEBB form for verifying your family members. To keep a family member on your coverage provide a copy of the following document(s) to us by November 30, 2009. You also must include the full name of the primary subscriber and the last four numbers of their social security number.

To provide proof of eligibility for this type of family member…	You must provide a copy of these documents
Spouse	·   Page 1 of your 2008 federal tax return that shows the spouse’s name (black out all financial information) OR ·   Marriage certificate AND one of the following: current proof of common residence (such as a mortgage note or lease agreement), financial interdependency (such as a shared bank account—please black out account information), or shared utility bill OR, if you cannot provide any of the above, we will accept:    ·                    Driver’s licenses showing the same physical address ·                    A shared credit card bill ·                    A shared vehicle title or lease ·                    A shared vehicle registration ·                    Two pieces of junk mail; one addressed to the subscriber and the other addressed to the spouse; both listing the same address ·                    A copy of a DEERS (Defense Enrollment Eligibility Reporting System) form – applies to members in active military service.
Qualified/registered domestic partner	Certificate of state-registered domestic partnership or registration card from the Washington Secretary of State’s Office OR ·   Completed Declaration of Marriage or Qualified Domestic Partnership form AND one of the following: current proof of common residence (such as a mortgage note or lease agreement), financial interdependency (such as a shared bank account—please black out account information), or shared utility bill
Dependent child through age 19	Any one of the following: ·   Page 1 of your 2008 federal tax return that shows the child’s name as a dependent (black out all financial information). You must send this document if your dependent child is married. ·   Birth certificate showing the name of the parent who is the subscriber or the subscriber’s spouse or qualified/registered domestic partner ·   Certificate or decree of adoption or legal documentation that shows you have assumed a legal obligation for total or partial support in anticipation of adoption ·   Court-ordered parenting plan showing health coverage obligation
Unmarried dependent student age 20-23   Note: Do not include proof of your student’s attendance—we will continue to review this through a separate process.	Any one of the following: ·   Page 1 of your 2008 federal tax return that shows the child’s name as a dependent (black out all financial information) ·   Birth certificate showing the name of the parent who is the subscriber or the subscriber’s spouse or qualified/registered domestic partner ·   Certificate or decree of adoption, or legal documentation that shows you have assumed a legal obligation for total or partial support in anticipation of adoption ·   Court-ordered parenting plan showing health coverage obligation
Married dependent student Note: Do not include proof of your student’s attendance—we will continue to review this through a separate process.	Any one of the following: ·   Page 1 of your 2008 federal tax return that shows the child’s name as a dependent (black out all financial information) ·   Birth certificate showing the name of the parent who is the subscriber or the subscriber’s spouse or qualified/registered domestic partner ·   Certificate or decree of adoption, or legal documentation that shows you have assumed a legal obligation for total or partial support in anticipation of adoption ·   Court-ordered parenting plan showing obligation for child’s health coverage

Send the documentation in the HCA return envelope sent to you or mail it to:  

Washington State Health Care Authority

Public Employees Benefits Board

PO Box 42685

Olympia WA 98504-2685