Instructions: Provide the completed signed form to RCUH and retain a copy for yourself.
In compliance with the Patient Protection Affordable Care Act (ACA), Employees who are currently waiving health benefits at this
time must submit this form to RCUH Human Resources as an agreement that he/she is still opting to waive health coverage. As a
condition of employment or continued employment, an employee deemed eligible for the RCUH medical plan must elect or waive
coverage with the RCUH. The RCUH reserves the right to deny an employee’s continued employment for non-compliance of our
election/waiver of medical coverage requirement. Information about the Individual Shared Responsibility Payment can be obtained
from the Internal Revenue Service’s website: (http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/Questions-and-
I have cancelled or waived coverage from RCUH’s medical plan because:
I (and if applicable, my eligible dependents) prefer not to have coverage. (I am declining health
I (and if applicable, my eligible dependents) have coverage with another party (i.e. parent, spouse,
domestic partner, civil union partner, or my own coverage purchased directly from a health insurance
I (and if applicable, my eligible dependents) have or will have coverage through the Federal Health
Insurance Marketplace (HealthCare.gov).
I (and if applicable, my eligible dependents) have coverage such as Medicare, Medicaid, TRICARE,
COBRA, Veterans Program, or other coverage recognized by the Secretary of Health and Human Services
as minimum essential coverage.
By signing this waiver form I am acknowledging the following:
• I understand that RCUH has given me an opportunity to enroll in RCUH’s Medical Plan for my eligible beneficiaries and
myself but I am voluntarily declining enrollment as indicated above.
• I understand that by declining RCUH’s Medical Plan at this time, I can only enroll in the future during RCUH’s Open
Enrollment Period or due to a Qualifying Event as defined by RCUH’s Policy 3.520 RCUH Health Plans.
• I further understand that providing inaccurate information or falsifying the information contained in this form may result
in disciplinary action including and up to termination of employment.
• I understand that I and (if applicable) eligible dependents will be ineligible for the Premium Tax Credit (PTC), since medical
coverage was offered through RCUH (employer-sponsored coverage).