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Objection to the National Medical Support Notice

  1. OBJECTION TO THE NATIONAL MEDICAL SUPPORT NOTICE
    Please fill this form out completely. If required documentation is not given, it will not be taken into consideration for this objection. This form CANNOT be saved. You CANNOT leave this form and return to it at a later time. Please review this form to make sure you have everything needed to complete it once you begin.
  2. Please indicate the name of your employer in which this document was sent.
  3. Cost to you per:
  4. The specific reason for the objection is (select ONLY ONE):
  5. 1.
  6. 2.
  7. Please provide all documentation in one upload if possible. If not, please use the additional documentation upload.
  8. 3.
    I am providing health care coverage for the child(ren) through other means (e.g. I have the child[ren] on Medicaid, my spouse is covering the child[ren] on his/her insurance, I have insurance for the child[ren] through another employer, etc).
  9. Please upload a copy of both sides into one document if possible. If not, please use the additional documentation upload.
  10. 4.
  11. 5.
  12. 6.
  13. Please provide any documentation that supports your objection
  14. Electronic Signature Agreement*
    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
  15. Leave This Blank:

  16. This field is not part of the form submission.