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S Authority on 0300 330 1343. HC5(O) Part 1 PATIENT S DETAILS Please use this part of the form to tell us about the patient: this may be you or the person on whose behalf you are making the claim. Surname: Other names: Title (Mr/Mrs/Miss/Ms/Other): Date of birth: / / National Insurance No: Address: Postcode: Telephone number including dialling code: ( ) This must be the number of the person signing at part 4 Part 2 NOTE DETAILS OF OPTICAL CHARGES PAID Please send us original recei.

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The 2023 Form HC-5 (Employee Notification to Employer) is available online at the Hawaii Department of Labor and Industrial Relations (DLIR) website. Use this form if the employee works at least 20 hours per week and: Works for 2 or more employers, or. Claims an exemption or waiver for health care coverage, or.

Use this form if the employee works at least 20 hours per week and: • Works for 2 or more employers** or. • Claims an exemption or waiver from health care coverage or. • Terminates an exemption or. • Changes principal and/or secondary employer designation**

Waiving medical coverage If an employee wishes to waive medical coverage, they must submit an HC-5 Waiver form to their employer, The form can be found on the State of Hawaii Disability Compensation Division website. The employer is responsible for filing the document with the DLIR.

Who is required to provide health care insurance coverage? All employers with one or more employees, whether full-time or part-time, permanent or temporary, are required to provide Prepaid Health Care Act coverage to their eligible employees in Hawaii unless the employees fall into an excluded category.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232