Get Agreement To Decline (opt-out) Medical Coverage - Ucm Mtabsc

Filling out the Agreement To Decline (Opt-Out) Medical Coverage form is a straightforward process designed to help employees of the Metropolitan Transportation Authority manage their medical coverage preferences. This guide will walk you through each step to ensure you complete the form accurately and efficiently.

Follow the steps to effortlessly complete the opt-out agreement form.

1. Click ‘Get Form’ button to obtain the Agreement To Decline (Opt-Out) Medical Coverage form, which you will need to complete online.
2. Begin with Section 1, where you should review the instructions carefully. This section explains the purpose of the form and provides contact information should you have any questions.
3. Proceed to Section 2, the Employee Information section. Fill in your details including your print name, BSC ID, agency affiliation, address, and contact information. Ensure that all fields are accurately completed.
4. In Section 3, Incentive Selection, choose the option that reflects your situation. You will need to initial your selection and understand the associated incentive which will be paid after the plan year.
5. Move to Section 4, Medical Coverage Information. Provide the necessary details about the medical plan you are opting out of, including the name of the insurance company and policyholder information.
6. In Section 5, Authorization, carefully read the statements and provide your understanding and consent by signing and dating the form. This step is crucial as it finalizes your decision to opt-out of medical coverage.
7. After completing all sections, save your changes and prepare the form for submission. You may need to print it to sign physically if required.
8. Finally, submit the signed form either by fax at 212-852-8700 or via email to bscservice@mtabsc.org.

Complete your Agreement To Decline (Opt-Out) Medical Coverage form online today!