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Written permission to reproduce or transmit this document in any form or by any means must be obtained from Marshfield Clinic Health System, Inc.Revised 02/01/22 Premium Rates (Level 1) 30+ Hours/week Plan year: April 1, 2022 – March 31, 2023. Health Insurance (Level 2) …
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Consent - Marshfield Clinic
www.marshfieldclinic.orgl I consent to care and treatment for my child related to his/her medical/dental/mental health treatment appointment at any of the following facilities: Marshfield Clinic, Inc., Family Health Center of Marshfield, Inc., Lakeview Medical
Consent Page 1 of 1 - Marshfield Clinic
www.marshfieldclinic.orgTo comply with Wisconsin law, Marshfield Clinic Health System requires that a parent (not step-parent/foster parent) or legal guardian (guardian appointed by a court) consent …
Health Insurance Employee Employer Total Per Pay Period ...
www.marshfieldclinic.orgEmployee +1 $231.49 $462.98 $1,349.43 $1,812.41 Employee + Children $245.34 $490.68 $1,418.19 $1,908.87 Family $267.37 $534.74 $1,569.18 $2,103.92 High Deductible Health Plan 3 Tier Plan Single $49.34 $98.68 $674.72 $773.40 Employee +1 $98.69 $197.38 $1,349.43 $1,546.81 Employee + Children $103.75 $207.50 $1,418.19 $1,625.69
Dental Benefit Comparison & Premium Rates
www.marshfieldclinic.orgReimbursement subject to Delta Dental’s Maximum Plan Allowance. (www.deltadentalwi.com, then select Delta Dental PPO or Premier) Deductible: Single $40/plan year Family $120/plan year Note: Deductible not applicable to diagnostic or preventive services. Annual maximum: $1,500/plan year (per person) (Does not include orthodontia)
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