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TheIowaStateAssociationofCountiesGroupHealthPlanNOTICES
DISCLOSURES
forthe20222023PlanYear
NoticeofHIPAASpecial
EnrollmentRights
Ifyouchosetodecline enrollment
for yourself or your dependents
(including
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How to fill out ifyouchosetodecline enrollment
How to fill out ifyouchosetodecline enrollment
01
Log in to your enrollment portal
02
Locate the option to decline enrollment
03
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04
Review your decision before submitting
Who needs ifyouchosetodecline enrollment?
01
Individuals who have decided not to enroll in a specific program or service
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What is ifyouchosetodecline enrollment?
If you choose to decline enrollment, it means you are opting out of participating in a particular program or service.
Who is required to file ifyouchosetodecline enrollment?
Individuals who do not wish to be enrolled or participate in a specific program or service may be required to file ifyouchosetodecline enrollment.
How to fill out ifyouchosetodecline enrollment?
To fill out ifyouchosetodecline enrollment, you may need to provide certain information to indicate your decision to decline enrollment.
What is the purpose of ifyouchosetodecline enrollment?
The purpose of ifyouchosetodecline enrollment is to formally indicate that you do not wish to be enrolled or participate in a specific program or service.
What information must be reported on ifyouchosetodecline enrollment?
The information required on ifyouchosetodecline enrollment may vary depending on the program or service, but typically includes your personal details and confirmation of your decision to decline enrollment.
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