Please note: There will be a cost associated with the addition of any Chapter 375 Dependent to your benefit plan. This additional cost will be between 65% and 70% of the employee-only rate of your chosen plan. This cost will be billed directly to the dependent. The first month's payment is required with submission of the application. Please check with your Benefits Office to obtain the exact amount for the first month's premium.
Other Forms:
Authorization to disclose private health information (HIPAA Release):
The Lance Group Release of Information Form
Voluntary Medical Benefits Waiver
Incentive Payment Form
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