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TRS-ActiveCare DECLINATION CERTIFICATION Group 085000 Spring Branch ISD TRS 1433 This is to certify that the available health coverage has been explained to me. I am declining coverage for myself and my spouse/dependents. Spouse name Reason for declining Other Group Coverage Medicare Medicaid Other explain Dependent Child name Signature Date Please mail completed form to 955 Campbell Road Houston TX 77024. Employee Name New Hire SSN Actively-at-work Date to be completed if a New Hire Open...
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How to fill out declination for electronic eligibility
How to fill out declination for electronic eligibility
01
Start by obtaining the electronic eligibility form from the designated authority.
02
Read the instructions carefully to understand the requirements and guidelines for filling out the form correctly.
03
Begin filling out the form by providing your personal details such as name, address, contact information, etc.
04
Next, provide all the necessary information related to your eligibility for the specific electronic service or program.
05
Double-check your responses to ensure accuracy and completeness.
06
In case you are not eligible for electronic eligibility, make sure to provide appropriate reasons and explanations.
07
Sign and date the declination form to certify its authenticity.
08
Submit the filled-out declination form to the concerned authority either in person or through the specified means.
09
Keep a copy of the filled-out form for your reference.
10
Follow up with the authority to confirm the receipt and processing of your declination for electronic eligibility.
Who needs declination for electronic eligibility?
01
Individuals who do not wish to avail or qualify for electronic eligibility for a specific program or service.
02
Those who are ineligible or do not meet the criteria for electronic eligibility.
03
People who prefer not to provide their personal information electronically.
04
Individuals who believe the electronic eligibility process may compromise their privacy or security.
05
Those who have opted for an alternative method of accessing the program or service.
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