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Updated: August 2015 COMPLETE ONLY IF YOU ARE DECLINING THE MEDICAL COVERAGE OFFERED BY Name) EMPLOYEE NAME (PRINT): (FIRST) (INITIAL) (LAST) EMPLOYEE ID NUMBER OR LAST 4 DIGITS OF SSN: I DECLINE TO ENROLL IN THE MEDICAL COVERAGE OFFERED FOR MYSELF AND MY ELIGIBLE DEPENDENTS. IN DECLINING SUCH COVERAGE, I UNDERSTAND THAT: Initial I am declining coverage for myself and my eligible dependents. Initial By declining coverage, I understand that I/we will not be eligible to enroll for such coverage under the plan(s) until the next open enrollment period, unless I meet the criteria stated below for a Special Enrollment exception. Initial If one of the Special Enrollment exceptions below applies, I understand that my eligible dependents and/or I will be considered eligible to enroll during the plan year, subject to the timelines stated in the exceptions and I will not have to wait for the next open enrollment period to obtain coverage under the plan(s). SIGNATURE: DATE SIGNED: SPECIAL ENROLLMENT Special Enrollment is a period of time allowed under this Plan, other than the eligible person’s Initial Enrollment Period or an Open Enrollment Period, during which an eligible person can request coverage as a result of certain events that create special enrollment rights. Special enrollment events include loss of other group health plan coverage. Also, in the event of marriage, birth, adoption or placement for adoption, you may enroll yourself and your newly acquired SPOUSE* and children for coverage. Coverage will become effective on the date of the event if an application for such coverage is received by the district office within sixty (60) days of the event. You or your eligible dependents may also have special enrollment rights in this Plan as a result of the loss of eligibility for coverage or becoming eligible for a premium subsidy under Medicaid or a state sponsored Children’s Health Insurance Program (CHIP). A request for enrollment must be submitted to the district office within sixty (60) days of loss of such coverage or the date of the Determination Letter advising of the eligibility for premium subsidy issued by either Medicaid or CHIP. You should consult with your local Medicaid or CHIP office regarding rights to the premium subsidy. HIPAA PRIVACY The III-A is fully compliant with the privacy provisions of the Health Insurance Portability and Accountability Act of 1996. IDAHO INDEPENDENT INTERGOVERNMENTAL AUTHORITY GROUP HEALTH PLAN DECLINATION OF COVERAGE FORM