If you checked the option for NO/NONE, please sign, date this form at the bottom and submit.
If you checked any of the other options above, you need to complete this form and submit it.
If you have other group insurance besides HealthChoice, you must provide information about your other coverage so HealthChoice can coordinate benefits with your other plan. Please do not leave any portion of this form blank and be sure to list the policy effective date as the earliest date of the policy. Also, please list the policy termination date, if applicable. Failure to submit this form in a timely manner will result in the delay or denial of your claims.