Get Waiver Of Coverage Form - Oklahoma - Coventry Health Care

Completing the Waiver Of Coverage Form is an essential step if you wish to decline medical coverage under your employer's plan. This guide provides clear, step-by-step instructions to help you fill out the form accurately and submit it online.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the form and open it in the online editor.
2. Fill in your first name in the designated *Employee First Name field.
3. Enter your last name in the *Employee Last Name field.
4. Provide your complete address, including street, city, state, and zip code in the *Address, *City, State, and *Zip fields.
5. Input your phone numbers, both home and work, in the corresponding *Home Phone and *Work Phone fields.
6. Enter the name of your employer in the *Group/Employer Name field.
7. Specify the effective date of medical coverage in the *Effective Date of Coverage field.
8. Indicate the reason you are waiving medical coverage by selecting an option in the *Reason waiving coverage field.
9. Provide details about your other medical insurance if applicable, including the insurer's name.
10. Sign and print your name in the designated *Employee Signature and *Employee Printed Name fields.
11. Add the date in the provided Date field.
12. Once all fields are completed, review your entries for accuracy. You can then save your changes, download the completed form, print it, or share it according to your needs.

Complete your Waiver Of Coverage Form online today to ensure your preferences are accurately documented.