University of Hawai‘i Part-time and Temporary Medical and Prescription Drug Plans Acknowledgement Calendar Year: _____________ I have been offered the opportunity to enroll in the medical and prescription drug plans for parttime and temporary employees. I have read the Part-time and Temporary Medical and Prescription Drug Plans memo regarding medical and prescription drug plans offered to State and County employees who are not eligible to enroll in EUTF’s medical/prescription drug plans. I understand participation in the part-time and temporary employees medical and prescription drug plans is voluntary, and if I wish to enroll, I will enroll directly with HMSA or Kaiser. Any questions relating to enrollment, coverage, payments and benefits will be directed to HMSA and/or Kaiser. HMSA and Kaiser contact information is available on the part-time and temporary employees medical and prescription drug plans memo. I understand under the Affordable Care Act (ACA), I may be subject to a penalty for not having health insurance coverage. Receipt acknowledged: Signature:
Date:
Name (print): HR representative or designee: I have provided the Part-time and Temporary Medical and Prescription Drug Plans memo to employee on: Date:
Hr rep or designee (print name)
Re-acknowledgement Employee’s signature:
Date:
HR representative or designee: I have provided the Part-time and Temporary Medical and Prescription Drug Plans memo to employee on: Date:
Hr rep or designee (print name)
Employee’s signature:
Date:
HR representative or designee: I have provided the Part-time and Temporary Medical and Prescription Drug Plans memo to employee on: Date:
Hr rep or designee (print name)
Employee’s signature:
Date:
HR representative or designee: I have provided the Part-time and Temporary Medical and Prescription Drug Plans memo to employee on: Date: UH Form 121 (OHR)
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Page 1 of 1. Short Course in Optical Engineering. Objective and Scope. Optical engineering is now common place in a variety of industrial systems and processes. The. advent of the laser and laser diodes and more recently LEDs with sensors and detecto
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This form was created in collaboration with the Center of Excellence in Diabetes and Endocrinology, UC Davis Medical Center, Kaiser Pediatric Endocrinology,.
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Jul 22, 2016 - Signature & Seal of Employer. Declaration ... Signature of the Candidate ... Attested copy of Document in support of source of funding. 4.
Jul 22, 2016 - Signature & Seal of Employer. Declaration ... Signature of the Candidate ... Attested copy of Document in support of source of funding. 4.
Player Cell Phone Player E-Mail Address. PARENT/GUARDIAN INFORMATION. Parent/Guardian 1. (Primary Contact). Last Name First E-Mail Address. Address ...
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Page 1 of 1. MANHATTAN SOCCER CLUB Medical and Waiver Form. Fall 2015 â Spring 2016. PLAYER INFORMATION. Last Name First Middle Initial Date of Birth Sex. Mo/Day/Yr M/F. Home Telephone. Address: Number and Street City/State/Zip School. Player Cell
Verzorging (onder leiding van dr DeRidder) en met de vertegenwoordigers van de farma-industrie (oa mr Leo. Neels) een gentiemen's agreement afgesloten, ...
There was a problem previewing this document. Retrying... Download. Connect more apps... Try one of the apps below to open or edit this item. SIJHSAA Concussion Acknowledgement and Consent Form 2016-2017.pdf. SIJHSAA Concussion Acknowledgement and Co
Working towards going totally organic on the baseball field and it will go through. one more baseball season with ... April 2016.pdf. April 2016.pdf. Open. Extract.
Magazine orders did not go out before Easter Weekend due to the snowstorm so unfortunate timing. Magazine. orders are due April 15. Melissa to ask Sandi ...
Medical care is available at your expense and this expense will not be assumed by the. Camp or Texas State University. Doctors are available at the University Medical Center during. the workday. I understand that in the event of serious illness or in
In case of an emergency involving me or my child, I understand that efforts will ... Part B: General Information/Health History ... Ear/eyes/nose/sinus problems.