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ELECTION TO WAIVE COVERAGE UNDER THE CATHOLIC DIOCESE OF CLEVELAND PROGRAM OF HEALTH CARE BENEFITS Name: (print clearly) Address: City, State, Zip Code: Social Security #: Date of Birth: Employer:

How to fill out election to waive coverage

How to fill out election to waive coverage:

1. Obtain the necessary form: Look for the specific form provided by your employer or insurance company to request a waiver of coverage. This form may also be available online on the company's website or through their human resources department.
2. Review the instructions: Read through the instructions on the form carefully. Ensure that you understand the requirements, deadlines, and any supporting documentation that may be required.
3. Fill out personal information: Provide your full name, address, contact information, and any other requested personal details at the top of the form. Make sure all information is accurate and up to date.
4. Determine eligibility: Check if you meet the eligibility criteria for waiving coverage. Common reasons for opting out of coverage may include having coverage through another source (such as a spouse's employer) or qualifying for a government program like Medicaid.
5. Provide supporting documentation: If required, gather any supporting documentation that proves your eligibility for waiving coverage. This may include copies of insurance policies or enrollment forms from other sources, proof of government program participation, or any other relevant documentation.
6. Read and sign the waiver statement: Carefully read the waiver statement provided on the form. It typically explains the consequences and implications of waiving coverage. If you agree to waive coverage, sign and date the form.
7. Submit the form: After completing the form and ensuring all required fields are filled out accurately, follow the instructions for submission. This may involve submitting the form to your employer's HR department, sending it through mail or email, or completing an online submission process. Be sure to meet any stated deadlines.

Who needs election to waive coverage?

Individuals who have access to employer-sponsored health insurance or any other type of insurance coverage for which they are eligible may need to complete an election to waive coverage. This is typically necessary when individuals have the option to enroll in their employer's health insurance plan but choose not to. Common reasons for choosing to waive coverage include already having coverage through another source, being eligible for a government healthcare program, or not needing the coverage provided due to personal circumstances. It is important to check with your employer or insurance provider to understand the specific requirements and eligibility criteria for waiving coverage.

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