This is the information needed to process your child’s TEFRA reevaluation.
- Please be sure to provide:
- your past year’s tax 1040 for determination of premium.
- a front/back copy of your child’s insurance card.
- Fill out the following forms either completely unless otherwise directed:
- Form 9700-Reevaluation Form
- Pub 408- Privacy Form
- 662 Form -Private insurance, please complete and include the front/back copy of your child’s insurance card
- 2602 Form -To be signed by your child’s physician. You will complete the top section 1 on p. 1; the bottom of p.2; the bottom of p.3; and the top of P.4. The doctor will complete the section re: prognosis and diagnosis and sign/date answer both questions on p. 4
- 4000 Form – you will complete the demographic info at the top of the page , where it says I, ____, you will write your name; sign/date parent on the second set of lines. Please be sure to leave the provider information blank.