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InfluenzaVaccination MedicalExemptionRequestFormPartA Instructions 1. Completeandsignthispage. 2. PresentPartBtoyourhealthcareprovidertocompletethemedicalinformation. 3. ReturnbothcompletedformstoCSMCentralCredentialsbyOctober31,2015.(Fax:414.326.7330).
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What is fax414?
fax414 is a form used to report information about the employer-sponsored health coverage provided to employees.
Who is required to file fax414?
Employers who provide health coverage to employees are required to file fax414.
How to fill out fax414?
fax414 can be filled out online or submitted through mail. Employers need to provide information about the health coverage offered to employees.
What is the purpose of fax414?
The purpose of fax414 is to provide the IRS with information about employer-sponsored health coverage.
What information must be reported on fax414?
Employers need to report information such as the number of employees receiving health coverage, the type of coverage offered, and the cost of coverage.
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