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 Verification of Alternative Coverage Please Fill Out This Form If You Are Waiving Your Right to Participate in Tufts Health Plan 2010

Verification of Alternative Coverage Please Fill Out This Form If You Are Waiving Your Right to Participate in Tufts Health Plan 2010

Use a Verification Of Alternative Coverage Please Fill Out This Form If You Are Waiving Your Right To Participate In Tufts Health Plan 2010 template to make your document workflow more streamlined.

If you have selected that you have coverage elsewhere please provide the following Carrier Name Subscriber Name Signature If you are declining enrollment for yourself or for your dependents including your spouse because of other health insurance coverage you may in the future be able to enroll yourself or your dependents in Tufts Health Plan provided that you request enrollment within 30 days after your coverage ends. Employee Information Employee Name Employer Group Reasons for Waiver I waive...
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