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Tobaccos Surcharge Affidavit If you are enrolling in an SCL Health medical plan and: If there is only one adult covered on the medical plan who currently uses or has used tobacco products within the
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How to fill out tobacco-use surcharge affidavit
How to fill out tobacco-use surcharge affidavit
01
Obtain a copy of the tobacco-use surcharge affidavit form from the appropriate agency or organization.
02
Read the instructions carefully to understand what information is required.
03
Fill out the form accurately and completely, making sure to provide all requested details about your tobacco use.
04
Sign and date the affidavit to certify that the information provided is true and accurate.
05
Submit the completed form to the designated recipient by the specified deadline.
Who needs tobacco-use surcharge affidavit?
01
Individuals who use tobacco products and are required to pay a surcharge based on their tobacco use may need to fill out a tobacco-use surcharge affidavit.
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What is tobacco-use surcharge affidavit?
The tobacco-use surcharge affidavit is a document used to report tobacco use by individuals and determine if they are subject to additional surcharges.
Who is required to file tobacco-use surcharge affidavit?
Individuals who use tobacco products and are enrolled in a health insurance plan may be required to file the tobacco-use surcharge affidavit.
How to fill out tobacco-use surcharge affidavit?
The tobacco-use surcharge affidavit can typically be filled out online or submitted through the mail by providing information about tobacco use and enrollment in a health insurance plan.
What is the purpose of tobacco-use surcharge affidavit?
The purpose of the tobacco-use surcharge affidavit is to determine if individuals using tobacco products should be subject to additional surcharges on their health insurance plan.
What information must be reported on tobacco-use surcharge affidavit?
Information such as tobacco use habits, enrollment in a health insurance plan, and other relevant personal details may need to be reported on the tobacco-use surcharge affidavit.
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