Health Care Acknowledgement Form
Health Care Acknowledgement Form Required Form Return Form to Human Resources
Employee Name_________________________________
Health Benefit Enrollment Status ☐ I hereby request Health Plan benefits for myself and my eligible dependents. I agree to the terms specified in any applicable health benefits certificate or other official description of the terms of my elected plans. I AUTHORIZE Park School to DEDUCT from my earnings the amount required to participate in the elected plans. I understand that my share of eligible (medical/vision and dental) group premium(s) will be automatically deducted pre-tax. I understand that if I do not want eligible premiums to be deducted pre-tax and prefer to be taxed on these dollars, I will contact the Human Resources Director. ☐ I decline Health Plan benefits at this time. I understand that unless I have a family status change within the meaning of the Internal Revenue Code section 125, I am not eligible to enroll until the next open enrollment period.
High Deductible Health Plan (HDHP) and Health Savings Account (HSA) I understand that I can only enroll for coverage in an HDHP plan with Park School if I am not enrolled in medical coverage elsewhere. I understand in order to establish a Health Savings Account (HSA), I must be classified as an eligible individual under IRC Section 223 meeting ALL of the following requirements: (1) I am covered under a High Deductible Health Plan (HDHP) AND (2) I am NOT COVERED by another non-HDHP health plan (including a general purpose FSA set up by you or your spouse) AND (3) I am not claimed as a dependent by another taxpayer AND (4) I am not enrolled in Medicare. I understand that my salary will continue to be reduced one year to the next by the amount indicated below providing I remain eligible to participate or until I complete and submit a revised Health Care Acknowledgement Form to Human Resources. I ELECT A PER PAY CONTRIBUTION OF $_______________ TO MY HSA EFFECTIVE __________________ Note: CONTRIBUTION AMOUNTS MAY NOT EXCEED IRS LIMITS. 2016 limits are: $3350 for individual and $6750 for family. Age 55+ catch up contribution is $1000
CHANGE OF CONTRIBUTION AMOUNT Consider changing your contribution amount annually to meet your needs and when the IRS limits and/or plan deductible and out-ofpocket limits change. Contributions may be increased, decreased, or stopped at any time of the year by completing and submitting a revised Health Care Acknowledgement Form. The form may be found on the Human Resources section of the Park website. Submit the completed form to Human Resources.
Signatures I understand this request will not be processed until all paperwork is completed, accepted, and approved by Park School. I also acknowledge that I have received notice of the Health Insurance Marketplace options available to me through the Affordable Care Act. This notice is posted in the Human Resources section of the Park website. Employee Signature: ______________________________________________ Date: ______________________
10/2014
Employee Name_________________________________
Health Benefit Enrollment Status ☐ I hereby request Health Plan benefits for myself and my eligible dependents. I agree to the terms specified in any applicable health benefits certificate or other official description of the terms of my elected plans. I AUTHORIZE Park School to DEDUCT from my earnings the amount required to participate in the elected plans. I understand that my share of eligible (medical/vision and dental) group premium(s) will be automatically deducted pre-tax. I understand that if I do not want eligible premiums to be deducted pre-tax and prefer to be taxed on these dollars, I will contact the Human Resources Director. ☐ I decline Health Plan benefits at this time. I understand that unless I have a family status change within the meaning of the Internal Revenue Code section 125, I am not eligible to enroll until the next open enrollment period.
High Deductible Health Plan (HDHP) and Health Savings Account (HSA) I understand that I can only enroll for coverage in an HDHP plan with Park School if I am not enrolled in medical coverage elsewhere. I understand in order to establish a Health Savings Account (HSA), I must be classified as an eligible individual under IRC Section 223 meeting ALL of the following requirements: (1) I am covered under a High Deductible Health Plan (HDHP) AND (2) I am NOT COVERED by another non-HDHP health plan (including a general purpose FSA set up by you or your spouse) AND (3) I am not claimed as a dependent by another taxpayer AND (4) I am not enrolled in Medicare. I understand that my salary will continue to be reduced one year to the next by the amount indicated below providing I remain eligible to participate or until I complete and submit a revised Health Care Acknowledgement Form to Human Resources. I ELECT A PER PAY CONTRIBUTION OF $_______________ TO MY HSA EFFECTIVE __________________ Note: CONTRIBUTION AMOUNTS MAY NOT EXCEED IRS LIMITS. 2016 limits are: $3350 for individual and $6750 for family. Age 55+ catch up contribution is $1000
CHANGE OF CONTRIBUTION AMOUNT Consider changing your contribution amount annually to meet your needs and when the IRS limits and/or plan deductible and out-ofpocket limits change. Contributions may be increased, decreased, or stopped at any time of the year by completing and submitting a revised Health Care Acknowledgement Form. The form may be found on the Human Resources section of the Park website. Submit the completed form to Human Resources.
Signatures I understand this request will not be processed until all paperwork is completed, accepted, and approved by Park School. I also acknowledge that I have received notice of the Health Insurance Marketplace options available to me through the Affordable Care Act. This notice is posted in the Human Resources section of the Park website. Employee Signature: ______________________________________________ Date: ______________________
10/2014
