Get Health Risk Premium Exemption Form

This guide provides step-by-step instructions on how to complete the Health Risk Premium Exemption Form online effectively. It is designed to assist users in navigating each section of the form to ensure accurate submission.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Section A must be filled out by the TeamHealth health insurance participant. Begin by entering your participant name clearly in the provided field.
3. Input your Employee Social Security Number, which is also required for your spouse or domestic partner. It's essential to keep this information confidential.
4. Provide your email address to facilitate communication regarding your submission.
5. Indicate your relationship status by checking the appropriate box: Employee, Spouse, or Same Sex Domestic Partner.
6. Fill in your date of birth accurately using the format provided.
7. Enter your Employee ID number in the designated field.
8. Select your gender by checking the corresponding box for Female or Male.
9. Address the health risk assessment and tobacco status by selecting 'Yes' or 'No' accordingly, and certify completion by signing in the designated area.
10. Read and acknowledge the privacy statement by signing and dating the form.
11. If a health screening result is not attached, Section B must be completed by a clinician. Ensure the clinician fills out the required health measurements.
12. Have the clinician print their name, phone number, and sign the form, including the date of service.
13. Once all sections are complete, you can either save changes, download, print, or share the form as needed.

Complete the Health Risk Premium Exemption Form online today to ensure your health information is accurately reported.