Get the free Tobacco Use Certification Form - busfin uga

This form is used by retirees and employees of the University of Georgia to certify their tobacco use status and that of their eligible dependents.

How to fill out tobacco use certification form

How to fill out Tobacco Use Certification Form

1. Obtain the Tobacco Use Certification Form from the relevant authority or website.
2. Fill in your personal information such as name, address, and contact details.
3. Specify your tobacco use status, indicating whether you are a current user, former user, or have never used tobacco.
4. Provide information on the duration and frequency of tobacco use, if applicable.
5. Sign and date the form to certify that the information provided is accurate.
6. Submit the completed form to the required authority or institution as instructed.

Who needs Tobacco Use Certification Form?

1. Individuals applying for health insurance plans that require tobacco use status disclosure.
2. Employees participating in workplace wellness programs that monitor tobacco use.
3. Patients undergoing medical assessments where tobacco use history may affect treatment.
4. Persons enrolling in certain programs or facilities that have tobacco-free policies.

People Also Ask about

What does an attestation form do?

An attestation form is a way of legally confirming that an accompanying document, such as a will, is authentic and that all relevant legal processes were followed in the making of it.

What is a signature attestation form?

An attestation is a certification that a document and the signatures within are valid. Attestations are generally found in wills and trusts. The attester should have no professional or personal association with either of the signatories.

How to fill an attestation form?

How to fill out the Government Attestation Form Instructions? Read the instructions thoroughly before starting. Fill in personal details accurately in the given fields. Provide information related to previous employment if applicable. Ensure all declarations are signed and dated appropriately.

What is tobacco attestation?

Back to top Open Enrollment. Tobacco attestation is the section of the enrollment process for the State Health Plan that asks about your tobacco use. All State Health Plan members MUST complete the tobacco attestation to avoid the default surcharge of $60 a month for the next year's premiums.

What is a tobacco use affidavit?

This form is used to determine your premium rate. You are only eligible for the lower non-tobacco user rate after you can attest that you use tobacco products, on average, less than four (4) times per week for six (6) months or longer.

In what forms is tobacco available?

Tobacco products encompass multiple varieties of products, including cigarettes, cigarette tobacco, roll-your-own tobacco, smokeless tobacco, electronic cigarettes, cigars, hookahs, pipe tobacco, nicotine gels, and dissolvables.

What is a tobacco attestation form?

The Tobacco Attestation Form asks employees to attest and certify to their current use or lack of tobacco use.

Do you use tobacco in any form?

Tobacco use may be defined as any habitual use of the tobacco plant leaf and its products. The predominant use of tobacco is by smoke inhalation of cigarettes, pipes, and cigars. Smokeless tobacco refers to a variety of tobacco products that are either sniffed, , or chewed.

For pdfFiller’s FAQs

What is Tobacco Use Certification Form?

The Tobacco Use Certification Form is a document used to certify an individual's tobacco use status, often for insurance or health-related purposes.

Who is required to file Tobacco Use Certification Form?

Individuals applying for certain health insurance policies or those participating in specific health programs may be required to file the Tobacco Use Certification Form.

How to fill out Tobacco Use Certification Form?

To fill out the Tobacco Use Certification Form, individuals typically need to provide personal information, indicate their tobacco use status, and sign the form verifying the accuracy of the information.

What is the purpose of Tobacco Use Certification Form?

The purpose of the Tobacco Use Certification Form is to assess an individual's tobacco use habits to determine eligibility for insurance premiums, health programs, and wellness initiatives.

What information must be reported on Tobacco Use Certification Form?

The information that must be reported includes the individual's name, date of birth, tobacco use history, type and frequency of tobacco products used, and a declaration of the truthfulness of the information provided.