New York Health Benefits Waiver Of Coverage printable pdf download

New York Health Benefits Waiver Of Coverage

New York Health Benefits Waiver of Coverage

Group Name:

Employee Name:

Marital Status

Single

Married

Widowed

Divorced

Date of Employment: __________/__________/__________

Date of Birth: __________/__________/__________

I was given the opportunity to enroll in a group health benefits plan offered by my employer

and insured by North Shore-LIJ CareConnect Insurance Company, Inc., and I have chosen to

refuse coverage.

Reason for Refusal

Spousal Waiver (coverage sponsored by my spouse’s employer)

Parental Waiver (coverage sponsored by my parents)

Medicaid

Medicare

Veteran coverage

Other coverage/Exchange coverage

Other reason

Please Provide

(where applicable):

Name of Carrier

Policy Number

__________/__________/__________

Employee Signature

Date

__________/__________/__________

Benefits Administrator Signature

Date

North Shore-LIJ CareConnect Insurance Company, Inc.

Attn: Group Enrollment

2200 Northern Boulevard, Suite 104, East Hills, NY 11548

855 - 706 - 7545

North Shore-LIJ CareConnect Insurance Company, Inc.

CC-NYHealthBenefitsWaiverofCoverage V2-08.14

New York Health Benefits Waiver Of Coverage