Get the free tobacco use certification form - ERS - Texas.gov

TOBACCO USE CERTIFICATION FORM Send this completed form to: Employees Retirement System of Texas P.O. Box 13207 Austin, Texas 787113207 or Fax: (512)8677438Information provided to ERS is maintained

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 institution.
2. Read the instructions and requirements carefully before filling out the form.
3. Provide your personal information such as name, address, contact details, and date of birth.
4. Indicate whether you are a current tobacco user or if you have quit within a specific period.
5. Specify the type and frequency of tobacco use, such as cigarettes, cigars, or smokeless tobacco.
6. Answer additional questions related to tobacco use, such as health conditions or previous attempts to quit.
7. Sign and date the form to certify the provided information is true and accurate.
8. Submit the completed form according to the designated submission method, either in person or through mail.
9. Keep a copy of the filled-out form for your records.

Who needs tobacco use certification form?

1. Individuals who are required to provide evidence or certification of their tobacco use status may need the tobacco use certification form. This may include employees in certain industries, individuals applying for health insurance, or those participating in various programs or studies related to smoking or tobacco use.

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What is tobacco use certification form?

The tobacco use certification form is a document used to verify an individual's tobacco use status, often required for health insurance purposes, workplace policies, or compliance with state regulations.

Who is required to file tobacco use certification form?

Individuals who are enrolled in certain health insurance plans or programs that require disclosure of tobacco use status are typically 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 must provide personal information, disclose their tobacco use status, and sign the form to certify the accuracy of the information provided.

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 for purposes such as determining insurance premiums, eligibility for health programs, and compliance with regulations.

What information must be reported on tobacco use certification form?

Information typically reported on the form includes the individual's name, contact information, details of tobacco use habits (e.g., type of tobacco used, frequency), and a declaration or certification of the truthfulness of the information.