Health Coverage
Waiver Form
Employer Group Name:
Employee Name:
On behalf of myself and my eligible dependents (if any), I waive the option to enroll in Mass General Brigham Health
Plan
health insurance offered at this time by or through my employer for the following reason:
O
I am covered under another plan as a spouse or dependent
O
I am covered under another health plan sponsored by my employer
O
I am covered under Medicare or Medicaid
O
I do not wish to participate in health care benefits at this time
O
Other
If you are declining to enroll in Mass General Brigham Health Plan at this time because of other health care
coverage,
please provide the following information.
Insurer Name:
Group Policy Number
I understand that any person choosing to enroll later must meet Mass General Brigham Health Plan’ requirements
for
eligibility and for late enrollees.
Employee
Signature: Date:
Employer
Signature: Date:
Notice of Enrollment rights:
If you are declining enrollment for yourself or 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 this health plan, provided that you request
enrollment within 60 days after your 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 your dependents, provided that you
request enrollment within 60 days after the marriage, birth, adoption or placement for adoption.
399 Revolution Drive, Suite 810, Somerville, MA 02145 | massgeneralbrighamhealthplan.org
Mass General Brigham Health Plan includes Mass General Brigham Health Plan, Inc. and Mass General Brigham Health Plan Insurance Company
