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Refusal of Coverage Instructions

Please refer to Medical Insurance Declination/Refusal form.

If, for whatever reasons, a resident or postdoctoral scholar qualified for Human Resources Medical Insurance coverage declines to enroll, they must then fill out a Medical Insurance Refusal form. It is a simple form, requiring only the first, middle and last name, date of birth, SSN, department, date of hire and signature with date. We have identified the carriers and policy numbers on the form.

Your tasks, as the Residents & Postdoctoral Scholars Insurance Coordinator, are:

  1. Copy the completed form for your records.
  2. Copy the completed form for the individual refusing the insurance, because it gives the conditions under which they might become eligible to enroll in the future.
  3. Send the original form to the Human Resources Office, Insurance Desk, Box 0832. We would prefer a cover note that identifies you, your department, and contact information.

This form is not optional for the person who refuses the Human Resources insurance coverage.