Small Group Waiver Form.qxd

SMALL EMPLOYER WAIVER FORM
Please Print
UTAH
10421 South Jordan Gateway
Suite 400
South Jordan, Utah 84095
EMPLOYEE INFORMATION
Employee Name: ____________________________________________________ Employer: ________________________________________________
WAIVER INFORMATION
I understand that I am eligible to participate in the group health plan offered through my employer and
have been given the opportunity to do so. I DO NOT want coverage. I am declining coverage at this time
due to the following:
o I currently have coverage elsewhere
o Covered by Medicaid
o Covered by Medicare
o Individual policy
o Group continuation coverage (COBRA) o Other
CURRENT HEALTH INSURANCE INFORMATION (This section must be completed)
Policy Holder’s Name: _______________________________________________ Relationship to Policy Holder: ____________________________________
Insurance Carrier: ____________________________________________
Policy Type:
o Individual
o Group
Policy Number: _____________________ Effective Date: ___________________
Employer Name: ___________________________________________________________________________
HEALTH INFORMATION If you answer “Yes” to any question below, please explain in space provided.
1. Have you or any of your dependents had any medical conditions or treatment in
o Yes o No
the past 24 months requiring medical care or hospitalization in the amount of
$5,000 or more? If so, for what condition(s)? ____________________________________________________________________________________
2. Are you or any dependent(s) currently pregnant or suspect you/they might be pregnant? o Yes
If yes, due date? ___________________________________________
o No
3. Are you or any of your dependents anticipating hospitalization or surgery or have you
o Yes o No
or any of your dependents had hospitalization or surgery recommended which has not
been performed? If so, for what condition(s)? ____________________________________________________________________________________
4. Has anyone taken prescription medication for more than two weeks in the past
o Yes o No
12 months? If so, please list names of medication(s) and condition(s). ________________________________________________
CHAL0110R01-06
SIGNATURE (This form must be signed)
I understand that if I and/or my dependent(s), if any, waive coverage, I may not again be eligible for coverage until the next open
enrollment period, which is established by my employer and Altius. If I am declining enrollment for myself or my dependents
(including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my
dependents in this plan if I or my dependents lose eligibility for that other coverage (or if the employer stops contributing towards
my or my dependents' other coverage). However, I must request enrollment within 30 days after my or my dependents' other coverage ends (or after the employer stops contributing toward the other coverage). In addition, if I have a new dependent as a result of
marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my dependents. However, I must request
enrollment within 30 days after the marriage, birth, adoption, or placement for adoption. Requests for special enrollment or more
information may be directed to Altius Health Plans, Customer Service Department, 801-323-6200 or 800-377-4161.
Employee Signature: ____________________________________________________________________
Date Signed: ___________________________________