Get State Of Idaho Declination Of Insurance Coverage

Filling out the State Of Idaho Declination Of Insurance Coverage form online is a straightforward process. This guide will help you understand each section of the form, ensuring that you complete it accurately.

Follow the steps to complete the form successfully.

1. Click ‘Get Form’ button to obtain the form and access it in the editor.
2. In the 'Your Name' section, enter your first name, middle initial, and last name as they appear on your official documents.
3. Next, provide your 'Mailing Address.' Make sure to include your street address, city, state, and zip code for correspondence.
4. If you are currently enrolled, fill in your 'Blue Cross ID Number.' If not applicable, you may leave this section blank.
5. In the 'Date of Birth' field, fill in your date of birth in the format specified (MM/DD/YYYY).
6. Select your gender by marking either 'Male' or 'Female.' Alternatively, you may choose not to disclose this information.
7. Provide your 'Phone Number' using the format (XXX) XXX-XXXX for consistency.
8. Indicate the 'State Agency or department from which you are retired.' Ensure the name is accurate to avoid processing issues.
9. Read the statement regarding declining benefits carefully and ensure you understand that you may be eligible to reinstate coverage later.
10. Enter the 'Effective Date' when you wish the declination to take effect.
11. Sign the form in the 'Signature' section, confirming your decision to decline benefits, and fill in the date of signing.
12. Finally, review all provided information for accuracy. Once confirmed, you can save changes, download, print, or share the completed form.

Complete your State Of Idaho Declination Of Insurance Coverage form online today!