As a new full-time employee, you have the opportunity to enroll in our Group Health Plan during your initial enrollment period. If you do not elect to enroll yourself or your dependents in the health plan during your initial enrollment period, you will not be able to enroll yourself or your dependents in the future unless you qualify for a ‘special enrollment right’ or until the next annual open enrollment period.

SPECIAL ENROLLMENT RIGHTS
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. In addition, if you
have a new dependent as a result of marriage, birth, adoption, or placement for adoption (common-law spouses do not qualify), you may be able to enroll yourself and your dependents, provided that you request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

 

I acknowledge receipt of a copy of this notice regarding the Health Insurance Portability and Accountability Act (HIPAA), under my employer’s group health plan. I am aware that if I do not elect health coverage for myself or my dependents during the initial enrollment period, my dependents and I must wait until the next enrollment period to enroll in my employer’s group health plan, unless we have a special enrollment right or lose our other health coverage.