Enroll Dependents up to Age 26

To add your newly eligible child(ren) to your Self and Family enrollment, please complete the information below and select Submit to send this form by email to GEHA. After we receive your submission, GEHA might follow up with you to ask for a copy of your child's birth certificate or other documentation in order to verify eligibility for coverage.

Please note: This form is NOT for use for the FEDVIP dental plan. To add dependents to your FEDVIP enrollment, please call BENEFEDS at (877) 888-3337.

    Member Information

    To help us identify your account, please provide the following information.





    Dependent Information

    Please provide the following information about the dependent you would like to add to your Self and Family coverage.








    Signature