Get Tobacco Attestation Broward Health Has Established Different Bb - Browardhealth

The Tobacco Attestation form is essential for establishing your medical premium rates at Broward Health based on tobacco usage. This guide provides step-by-step instructions to help you complete the form accurately, ensuring you comply with the requirements and avoid unnecessary costs.

Follow the steps to complete the Tobacco Attestation form effectively.

1. Press the ‘Get Form’ button to access the Tobacco Attestation form and open it for editing.
2. Begin by reviewing the form's purpose, which is to confirm your tobacco usage status. You will find sections for both yourself and your spouse/domestic partner.
3. In the 'Employee Attestation' section, check either box A or B. If you have used tobacco products within the last six months, select box A. If you have not used tobacco products in that timeframe, select box B.
4. Proceed to the 'Spouse/Partner' section. If your spouse/domestic partner is also enrolled in a Broward Health Medical Plan, check either box C or D. Select C if your spouse/partner has used tobacco products in the last six months, or select D if they have not.
5. Ensure all statements reflect your truthful representations to avoid disciplinary action. Review the instructions on potential cost impacts based on your attestations.
6. Sign the form in the designated 'Employee Signature' field and enter the date of completion.
7. Print your name and employee number accurately in the spaces provided.
8. Upon completing all sections, save your changes. You can then download, print, or share the form as needed, ensuring timely submission.

Take action now by filling out the Tobacco Attestation form online to establish your correct medical premium rate.