Transcription of Waiver of Health Coverage - Instant Benefits
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Waiver of Health Coverage - Instant Benefits
13 SBG 10-08 Waiver of Health coverageI acknowledge that I have been offered the opportunity to purchase Health Coverage from Group Health Cooperative or Group Health Options, Inc. for myself and my dependents through my decline enrollment at this time because: I have other medical Coverage provided by: Insurance company name: Policy no. Through (employer name): I do not wish to enroll myself in any type of medical Coverage at this time. I do not wish to enroll my spouse child(ren) in any type of medical Coverage at this you are declining enrollment for yourself or dependents (including your spouse) because of other Health care Coverage , you may enroll yourself or your dependents in this plan prior to the next open enrollment period (under certain circumstances).
13SBG 10-08 Waiver of health coverage I acknowledge that I have been offered the opportunity to purchase health coverage from Group Health Cooperative or Group Health
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Florida Medicaid, Waiver, COVERAGE, Health, Of Health, Home and Community Based Services HCBS, DEFINITION – HEALTH CARE SAFETY NET, PATIENT PROTECTION AND AFFORDABLE, Patient protection and affordable care act, Patient protection and affordable care act health, Member Eligibility and Benefit Coverage, Instructions for completing a Health Benefits Application