Fillable To verify your eligibility to receive Premium Assistance (Health Equity)

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To verify your eligibility to receive Premium Assistance (Health Equity)

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The To verify your eligibility to receive Premium Assistance (Health Equity) form is 2 pages long and contains:

  • 5 signatures
  • 10 check-boxes
  • 60 other fields

Country of origin: US
File type: PDF

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To verify your eligibility to receive Premium Assistance under the American Rescue Plan Act of 2021 (ARPA), complete this form and return it
to WageWorks. If you have not yet elected COBRA continuation coverage, you may send this form along with your COBRA election form. If you
do not complete this form and return it within 60 days of the date of your notice, you may be unable to receive the premium assistance.
If you are already enrolled in COBRA, you may complete this form separately. If you choose to do so, send the completed “Request for Treatment
as an Assistance Eligible Individual” to: WageWorks, Inc. at PO Box 226101 Dallas, TX 75222-6101. You may also fax the completed form to
866.599.3141. You may also submit this information electronically at compliancedepartment@healthequity.com (PLEASE USE “Request for
Treatment as an AEI” IN YOUR EMAIL’S SUBJECT LINE).
For more information regarding ARPA premium assistance and eligibility questions, visit https://www.dol.gov/cobra-subsidy.
REQUEST FOR TREATMENT AS AN ASSISTANCE
ELIGIBLE INDIVIDUAL
P.O. Box 650407
Dallas, TX 75265-
0407
PERSONAL INFORMATION
Name, mailing address, and employee’s Account Number (if you do not
know the employee’s account number, please list the employee’s Social Security
number; list any dependents in the “Dependent Information” section of this form)
Primary Telephone number
E-mail address (required)
To qualify, you must be able to check ‘Yes’ for all statements.
1. The qualifying event was an involuntary termination of employment or a reduction in hours.
Yes No
2. I elected (or am electing) COBRA continuation coverage.
Yes No
3. I am NOT eligible for other group health plan coverage (or I was not eligible for other group health plan coverage
during the period for which I am claiming premium assistance).
Yes No
4. I am NOT eligible for Medicare (or I was not eligible for Medicare during the period for which I am claiming premium
assistance).
Yes No
I make an election to exercise my right to ARPA premium assistance and attest that I meet the requirements for treatment as an
Assistance Eligible Individual. To the best of my knowledge and belief all of the answers I have provided on this form are true and
correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
FOR EMPLOYER OR PLAN USE ONLY
This request is: Approved Denied Specify reason in #3 below and return a copy of this form to the applicant.
REASON FOR DENIAL OF TREATMENT AS AN ASSISTANCE ELIGIBLE INDIVIDUAL
Signature of employer, plan administrator, or other party responsible for COBRA administration for the Plan
__________________________________________________ Date ____________________________
Type or print name _____________________________________________________________________________
Telephone number ____________________________ E-mail address ____________________________
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For Further Assistance, you may contact the Department of Labor’s Employee Benefits
Administration at 1-866-444-3272, or online at https://www.askebsa.dol.gov/WebIntake.
DEPENDENT INFORMATION (Parent or guardian should sign for minor children.)
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage.
Yes No
2. I am NOT eligible for other group health plan coverage.
Yes No
3. I am NOT eligible for Medicare.
Yes No
4. The qualifying event was an involuntary termination or a reduction in hours.
Yes No
I make an election to exercise my right to ARPA premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage.
Yes No
2. I am NOT eligible for other group health plan coverage.
Yes No
3. I am NOT eligible for Medicare.
Yes No
4. The qualifying event was an involuntary termination or a reduction in hours.
Yes No
I make an election to exercise my right to ARPA premium assistance. To the best of my knowledge and belief all of the answers I have
provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee _________________________
. _________________________________________________________________________
1. I elected (or am electing) COBRA continuation coverage.
Yes No
2. I am NOT eligible for other group health plan coverage.
Yes No
3. I am NOT eligible for Medicare.
Yes No
4. The qualifying event was an involuntary termination or a reduction in hours.
Yes No
I make an election to exercise my right to the ARPA premium assistance. To the best of my knowledge and belief all of the answers I
have provided on this form are true and correct.
Signature __________________________________________________ Date ____________________________
Type or print name __________________________________________ Relationship to employee ______________________
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
Name
Date of Birth
Relationship to Employee
SSN (or other identifier)
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To verify your eligibility to receive Premium Assistance (Health Equity)

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Completed 17 June 2021

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