Human Resources
Check Your Spouse’s Coverage Situation Below
My spouse is enrolled in (or requesting to be enrolled in) Summa’s medical coverage because
they do not have access to other group medical coverage.
•
Unemployed
•
My spouse has access to other medical coverage through their own employer, but
cannot enroll until . I know I am responsible for removing my
spouse from Summa Health’s medical plan at that time.
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Group Coverage Not Oered Through Their Employer
Spouse’s Employer’s Name Phone
My spouse also works for Summa Health and is on my plan or on their own plan through Summa.
I arm that the above stated facts are true and correct. I further understand that if it
should be found as fraud, disciplinary action, up to and including termination, may occur.
Employee Name ID #
Employee Signature Date
Return this form to: summabenefi[email protected]
Spousal Medical Coverage Adavit
be on Summa Health’s medical plan. If your spouse declines coverage oered through
their employer’s group medical plan, they cannot be on Summa Health’s medical plan.
Please review and check the appropriate box below. Depending on your selection,
your spouse may or may not be eligible for Summa Health’s medical coverage.
HUR-21-57456/CS/RH/12-21
