Health Tradition Member Enrollment Form Page 3
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3Coverage is being waived for myself or my family for the following reason:
Waiver
Section
❏ Covered under my spouse’s group health plan
❏ Covered under an individual health insurance policy
❏ Other __________________________________________________________________________________________
To be
If waiving due to other coverage, please provide the name(s) of individual(s) waiving coverage:
completed
_________________________________________________________________________________________________
only if
refusing
If you are waiving/declining medical coverage for yourself and/or your dependents (including your spouse) because of
other health coverage, you may in the future be able to enroll yourself and/or your dependents when other coverage ends,
coverage
provided that you request enrollment within 30 days after other coverage ends.
In addition, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you may be
able to enroll yourself and/or your dependents provided that you request enrollment within 30 days after the marriage, birth,
adoption or placement for adoption.
If you waive/decline medical coverage for yourself and/or dependents for any other reason, you may not enroll outside of
an open enrollment period, if any.
I proclaim that I was not pressured or forced by the employer named above, the writing agent, Health Tradition Health Plan, or
Mayo Clinic Health Solutions into waiving the above noted coverage. I freely and voluntarily waive the above noted coverage.
Signature Required
Signature Required
__________________________________________
__________________________________________
Employee Signature
Date Signed
Spouse Signature
Date Signed
221-HTH214 (10/14)
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