Tobacco Surcharge Physician Affidavit Form Preview on Page 1

Tobacco Surcharge Physician Affidavit Form 2026

The Tobacco Surcharge Physician Affidavit Form outlines the process for Compass Group associates who use tobacco products to waive a surcharge on their medical plan. Associates must certify non-use of tobacco for six months or participate in a cessation program provided by Compass Group. If unable to meet these requirements due to health reasons, a physician can attest to the associate's condition and recommend an alternative program. The form requires signatures from both the physician and the associate.

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Definition and Purpose of the Tobacco Surcharge Physician Affidavit Form

The Tobacco Surcharge Physician Affidavit Form is used primarily by Compass Group associates who use tobacco products and are enrolled in a company medical plan that incurs a surcharge. This form allows physicians to certify that an associate either does not use tobacco or has enrolled in a cessation program. If the associate is unable to meet these conditions due to medical reasons, the physician attests to this, potentially waiving the surcharge obligation.

How to Use the Tobacco Surcharge Physician Affidavit Form

Certification of Non-Use: Associates who do not use tobacco for a consecutive six-month period can use this form to certify their exemption from the surcharge.
Enrollment in Cessation Programs: Participants already involved in cessation programs may certify their efforts for surcharge waiving.
Medical Attestation: For those unable to participate due to health restrictions, physicians can document the condition and suggest alternative programs or considerations.

Acquiring the Tobacco Surcharge Physician Affidavit Form

The form can be obtained through the employer's human resources department. It may also be available online through the Compass Group's employee portal or by direct request from the company's benefits department.

Steps to Complete the Tobacco Surcharge Physician Affidavit Form

Employee Section:
- Fill in personal information including name, employee ID, and contact details.
- Indicate the choice of qualification, e.g., cessation program participation or medical exemption.
Physician Section:
- The physician certifies the non-usage or health-related exemption.
- Include physician's contact details and license number.
Signatures:
- Required signatures from both the associate and the physician to validate the form.

Why You Should Complete the Tobacco Surcharge Physician Affidavit Form

Completing the form can lead to significant savings by avoiding the tobacco surcharge associated with the medical plan. For those genuinely unable to quit tobacco due to health issues, this form provides a structured means for negotiating alternatives.

Typical Users of the Tobacco Surcharge Physician Affidavit Form

This form is primarily used by Compass Group employees enrolled in their health insurance plans who are subject to a tobacco surcharge. It can also involve healthcare professionals who support employees in certifying their eligibility for waiver through medical attestation.

Key Components of the Tobacco Surcharge Physician Affidavit Form

Employee Information: Fields for personal and employment details.
Certification Type: Specifies exemption type—cessation participation or medical condition.
Physician Validation: Area designated for physician’s details and certification.
Signature Fields: Mandatory for both employee and physician sign-offs.

Digital vs. Paper Version of the Form

The form may have both digital and paper versions for submission. The digital version can often be filled out and submitted online for faster processing, while the paper version typically requires manual filling and submission through mail or in person. Digital submission may offer advantages such as error-checking features and immediate receipt confirmation.