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Medical Benefits Spouse/Partner Enrollment Attestation Form

This form applies to associates who would like to enroll/have enrolled their spouse/civil union partner for medical benefits under Prime Healthcare’s Health Plan.

Associate Full Name (Last, First)

DOB

Last 4 SSN

Facility/Hospital

Email

Open Enrollment – Effective Year

By signing below, I certify that:

I understand that, if my spouse and/or civil union partner is eligible for medical coverage under their own employer’s plan, they are not eligible to enroll in Prime Healthcare’s medical plan. However, they can enroll in Prime Healthcare’s dental, vision, and dependent life plans.

I certify that (choose the one statement below that applies to you):

I certify that (choose the one statement below that applies to you):

I understand that, if my legal relationship with my spouse or civil union partner ends or if my spouse or civil union partner is or becomes eligible for medical insurance or contribution from their employer at any time during the coverage period.

I certify that the information I have provided on this form, and at any time thereafter, about my family status and my dependents’ eligibility for benefits under Prime Healthcare’s plan is complete and accurate.

Fraud Warning: I understand that any person who knowingly, and with intent to defraud any insurance company, or other person, files an application for insurance or a statement of claim containing any materially false information, or conceals information concerning any fact material thereto, for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I understand that the Plan reserves the right to rescind coverage and to recoup any amounts expended in providing coverage to the fullest extent permissible by law in the event of fraud or a material misrepresentation.