SSM Health employee out-of-area dependent form

If you or a covered family member reside outside of the SSM Employee Health Plan network service area, you may be eligible to have your medical claims covered as out of area.

To find out more or search for providers, visit firsthealth.com.

Before seeking medical care with First Health providers, we suggest confirming your provider's First Health network participation status at firsthealth.com. Find out how to search for a First Health provider.

If you have questions, contact the Customer Care Center at 877-274-4693.

Notify us

To determine if you are eligible, review the list of SSM Employee Health Plan network zip codes. If your home zip code isn't listed, complete and submit this form.

This benefit is for SSM Health employees enrolled in the health plan. If you have questions about your health plan and covered benefits, contact the Customer Care Center at 877-274-4693 (TTY:711).

* Required field

Employee first name*

Employee last name*

Employee member number*

Out-of-area dependent first name*

Out-of-area dependent last name*

City*

State*

ZIP*

Relocation date*

Out-of-area dependent 2 first name

Out-of-area dependent 2 last name

City

State

ZIP

Relocation date

Out-of-area dependent 3 first name

Out-of-area dependent 3 last name

City

State

ZIP

Relocation date

Out-of-area dependent 4 first name

Out-of-area dependent 4 last name

City

State

ZIP

Relocation date

Attestation

Knowingly submitting false information could result in disciplinary action up to and including termination of employment.

Eligibility information is subject to auditing. I certify that all information on this affidavit is true, correct and current as of the date submitted

Please confirm