Nassau New York Declaración jurada de no cobertura por otro plan de salud grupal - Affidavit of No Coverage by Another Group Health Plan

• Category: Empleo - Coronavirus - COVID-19 - Autorización
• State: Multi-State
• County: Nassau
• Control #: US-321EM
• Format: Word

Description

El empleado mencionado en esta declaración jurada da fe de que no está cubierto por ningún otro plan de salud grupal. The Nassau New York Affidavit of No Coverage by Another Group Health Plan is a legal document used in the state of New York to declare that an individual does not have coverage through another group health plan. This affidavit acts as proof that the person is not eligible for coverage under any other group health plan, allowing them to enroll in the desired health plan without any conflicts or complications. When completing the Nassau New York Affidavit of No Coverage by Another Group Health Plan, it is essential to provide accurate and detailed information. The following sections must be filled out correctly: 1. Personal Information: Include your full name, address, date of birth, Social Security number, gender, and contact details. This information is necessary to identify the person completing the affidavit. 2. Previous Coverage: State whether you have had any group health coverage within the past 30 days or if you are currently covered under any other group health plan. If the answer is yes, provide the relevant details, including the plan name, policy number, and termination date of the coverage. 3. Waiver of Group Health Coverage: Indicate whether you are eligible for, but voluntarily waive or decline group health coverage offered through your employer or any other organization. Specify the reason for this waiver, whether personal preference, coverage obtained elsewhere, or any other relevant explanation. 4. Acknowledgment of Penalties: Attest that you understand the consequences of providing false information in the affidavit. Clarify that you will be held responsible for any financial penalties or legal actions if the information provided is found to be inaccurate or misleading. Types of Nassau New York Affidavit of No Coverage by Another Group Health Plan: 1. Individual Affidavit: Used by individuals who are seeking coverage and can declare that they do not have any group health coverage through any other plan, including coverage through their employer or any other organization. 2. Family Affidavit: Similar to the individual affidavit, this type is used when the coverage extends to the family members of the enrolled. It affirms that all family members, including spouses and dependents, are not covered under any other group health plan. 3. Short-Term Affidavit: This affidavit is applicable for individuals seeking temporary coverage for a brief period, usually for job transitions, waiting for eligibility in another plan, or during a specific life event. It affirms that the person does not have coverage for the desired short-term period. Completing the Nassau New York Affidavit of No Coverage by Another Group Health Plan accurately and truthfully is crucial to ensure eligibility for the desired health plan. It is essential to consult with legal or healthcare professionals to ensure compliance with applicable laws and regulations.

The Nassau New York Affidavit of No Coverage by Another Group Health Plan is a legal document used in the state of New York to declare that an individual does not have coverage through another group health plan. This affidavit acts as proof that the person is not eligible for coverage under any other group health plan, allowing them to enroll in the desired health plan without any conflicts or complications. When completing the Nassau New York Affidavit of No Coverage by Another Group Health Plan, it is essential to provide accurate and detailed information. The following sections must be filled out correctly: 1. Personal Information: Include your full name, address, date of birth, Social Security number, gender, and contact details. This information is necessary to identify the person completing the affidavit. 2. Previous Coverage: State whether you have had any group health coverage within the past 30 days or if you are currently covered under any other group health plan. If the answer is yes, provide the relevant details, including the plan name, policy number, and termination date of the coverage. 3. Waiver of Group Health Coverage: Indicate whether you are eligible for, but voluntarily waive or decline group health coverage offered through your employer or any other organization. Specify the reason for this waiver, whether personal preference, coverage obtained elsewhere, or any other relevant explanation. 4. Acknowledgment of Penalties: Attest that you understand the consequences of providing false information in the affidavit. Clarify that you will be held responsible for any financial penalties or legal actions if the information provided is found to be inaccurate or misleading. Types of Nassau New York Affidavit of No Coverage by Another Group Health Plan: 1. Individual Affidavit: Used by individuals who are seeking coverage and can declare that they do not have any group health coverage through any other plan, including coverage through their employer or any other organization. 2. Family Affidavit: Similar to the individual affidavit, this type is used when the coverage extends to the family members of the enrolled. It affirms that all family members, including spouses and dependents, are not covered under any other group health plan. 3. Short-Term Affidavit: This affidavit is applicable for individuals seeking temporary coverage for a brief period, usually for job transitions, waiting for eligibility in another plan, or during a specific life event. It affirms that the person does not have coverage for the desired short-term period. Completing the Nassau New York Affidavit of No Coverage by Another Group Health Plan accurately and truthfully is crucial to ensure eligibility for the desired health plan. It is essential to consult with legal or healthcare professionals to ensure compliance with applicable laws and regulations.

Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés. For your convenience, the complete English version of this form is attached below the Spanish version.