Page 19 - The Polyclinic New Hire Guide
P. 19
Legal Spousal Eligibility Affidavit
The Polyclinic does not offer medical or dental coverage for a spouse who is eligible for other medical or dental
coverage through another creditable coverage plan.
Any employee electing to cover a spouse under a Polyclinic medical or dental plan is required to complete this
form.
Periodic audits will be conducted to ensure that The Polyclinic plans cover only eligible dependents. Should you
be selected for an audit, you may be asked to provide documentation verifying dependent eligibility.
If you have any questions regarding eligibility, please contact Sue Oien, ext 4519 or Tanya Triola ext 3821.
By signing below, I certify that my spouse , is NOT eligible for
coverage through his/her employer, .
Please state the reason that your spouse is not eligible (check all that apply).
Insurance is not offered to my spouse
My spouse does not meet the employer’s eligibility requirements
My spouse will not be eligible for his/her employer coverage until (month/year)
My spouse is not employed or is self-employed
If my spouse later becomes eligible for coverage through his/her employer, I am responsible for notifying a
Beneits representative within 31 days. At that time my spouse will be removed from The Polyclinic medical and
dental plans. I understand that if it is found that I am covering or have covered a spouse who is not eligible, I
will be legally responsible for paying back claims paid by First Choice on my spouse’s behalf. Further, I will be
responsible for reimbursing Polyclinic’s portion of premiums for the amount of time the spouse was covered
but not eligible for coverage under The Polyclinic medical or dental plans, without further action in a court of
competent jurisdiction.
Employee Signature:
Printed Name:
Date Signed:
Please keep a copy of this for your records.
The Polyclinic does not offer medical or dental coverage for a spouse who is eligible for other medical or dental
coverage through another creditable coverage plan.
Any employee electing to cover a spouse under a Polyclinic medical or dental plan is required to complete this
form.
Periodic audits will be conducted to ensure that The Polyclinic plans cover only eligible dependents. Should you
be selected for an audit, you may be asked to provide documentation verifying dependent eligibility.
If you have any questions regarding eligibility, please contact Sue Oien, ext 4519 or Tanya Triola ext 3821.
By signing below, I certify that my spouse , is NOT eligible for
coverage through his/her employer, .
Please state the reason that your spouse is not eligible (check all that apply).
Insurance is not offered to my spouse
My spouse does not meet the employer’s eligibility requirements
My spouse will not be eligible for his/her employer coverage until (month/year)
My spouse is not employed or is self-employed
If my spouse later becomes eligible for coverage through his/her employer, I am responsible for notifying a
Beneits representative within 31 days. At that time my spouse will be removed from The Polyclinic medical and
dental plans. I understand that if it is found that I am covering or have covered a spouse who is not eligible, I
will be legally responsible for paying back claims paid by First Choice on my spouse’s behalf. Further, I will be
responsible for reimbursing Polyclinic’s portion of premiums for the amount of time the spouse was covered
but not eligible for coverage under The Polyclinic medical or dental plans, without further action in a court of
competent jurisdiction.
Employee Signature:
Printed Name:
Date Signed:
Please keep a copy of this for your records.
