District of Columbia Small Group Business Employee Enrollment Change Form 67834-6 0413-2026

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District of Columbia Small Group Business Employee Enrollment Change Form 67834-6 0413 Preview on Page 1

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by filling out the Employer Name and Effective Date at the top of the form. Ensure accuracy as this information is crucial for processing.
  3. In Section A, provide your Employee Information including Social Security Number, Job Title, and Home Address. Be thorough to avoid delays.
  4. If you are waiving coverage, complete Sections A and B. In Section B, indicate which coverage (medical/dental) you are declining and provide a reason if applicable.
  5. Proceed to Section C for Coverage Selection. Clearly print your choices using black ink, ensuring all required fields are filled out correctly.
  6. Complete Sections D through I as necessary, providing details about dependents and any prior health coverage. This information is vital for eligibility.
  7. Before submitting, review all entries for completeness and accuracy. Use our platform’s features to save or print your completed form securely.

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