Form - Benefits Acknowledgement and Declination - HomeCentris Healthcare

Form – Benefits Acknowledgement and DeclinationMatt Auman2023-08-30T16:44:37-04:00

Benefits Acknowledgement and Declination

Benefits Offer Acknowledgement - Plan Year 2024

Benefits Offer Acknowledgement - Plan Year 2024

Date

Employee Name: *

Authorization

I acknowledge that I have been offered health coverage by my employer HomeCentris for the benefit period ending on September 30, 2024.  I have been given a summary of the health benefits offered and the employee contribution amount required to receive health coverage. 
                                                                                                                                       
I also understand that my election (to waive or enroll in health coverage) is irrevocable (cannot be reversed) for the benefit period ending on September 30, 2024, unless I experience an event (qualified life event) which allows me to make a midyear election change.

Signature *

If you are human, leave this field blank.

img.wp-smiley,img.emoji{display:inline !important;border:none !important;box-shadow:none !important;height:1em !important;width:1em !important;margin:0 .07em !important;vertical-align:-.1em !important;background:none !important;padding:0 !important;}ul.pagination li.dots.disabled{padding:6px 8px;background-color:#fff;border:1px solid #ddd;}.frm_pagination_cont ul.frm_pagination{display:flex;}.frm_pagination_cont ul.frm_pagination > li{margin:0;}.input-group .form-control{margin-right:0;}@media screen and (max-width: 640px){.fusion-no-small-visibility{display:none !important;}body .sm-text-align-center{text-align:center !important;}body .sm-text-align-left{text-align:left !important;}body .sm-text-align-right{text-align:right !important;}body .sm-flex-align-center{justify-content:center !important;}body .sm-flex-align-flex-start{justify-content:flex-start !important;}body .sm-flex-align-flex-end{justify-content:flex-end !important;}body .sm-mx-auto{margin-left:auto !important;margin-right:auto !important;}body .sm-ml-auto{margin-left:auto !important;}body .sm-mr-auto{margin-right:auto !important;}body .fusion-absolute-position-small{position:absolute;top:auto;width:100%;}.awb-sticky.awb-sticky-small{position:sticky;top:var(--awb-sticky-offset,0);}}@media screen and (min-width: 641px) and (max-width: 1024px){.fusion-no-medium-visibility{display:none !important;}body .md-text-align-center{text-align:center !important;}body .md-text-align-left{text-align:left !important;}body .md-text-align-right{text-align:right !important;}body .md-flex-align-center{justify-content:center !important;}body .md-flex-align-flex-start{justify-content:flex-start !important;}body .md-flex-align-flex-end{justify-content:flex-end !important;}body .md-mx-auto{margin-left:auto !important;margin-right:auto !important;}body .md-ml-auto{margin-left:auto !important;}body .md-mr-auto{margin-right:auto !important;}body .fusion-absolute-position-medium{position:absolute;top:auto;width:100%;}.awb-sticky.awb-sticky-medium{position:sticky;top:var(--awb-sticky-offset,0);}}@media screen and (min-width: 1025px){.fusion-no-large-visibility{display:none !important;}body .lg-text-align-center{text-align:center !important;}body .lg-text-align-left{text-align:left !important;}body .lg-text-align-right{text-align:right !important;}body .lg-flex-align-center{justify-content:center !important;}body .lg-flex-align-flex-start{justify-content:flex-start !important;}body .lg-flex-align-flex-end{justify-content:flex-end !important;}body .lg-mx-auto{margin-left:auto !important;margin-right:auto !important;}body .lg-ml-auto{margin-left:auto !important;}body .lg-mr-auto{margin-right:auto !important;}body .fusion-absolute-position-large{position:absolute;top:auto;width:100%;}.awb-sticky.awb-sticky-large{position:sticky;top:var(--awb-sticky-offset,0);}}.recentcomments a{display:inline !important;padding:0 !important;margin:0 !important;}.broken_link,a.broken_link{text-decoration:line-through;}.tfs-button-1{position:relative;bottom:-250px;}.tfs-button-2{position:relative;bottom:-250px;}.fusion-tab-joinourteam{font-size:20px;}.fusion-page-title-captions{margin-top:200px;}.slide-content-container{margin-top:200px;}body{--wp--preset--color--black:#000;--wp--preset--color--cyan-bluish-gray:#abb8c3;--wp--preset--color--white:#fff;--wp--preset--color--pale-pink:#f78da7;--wp--preset--color--vivid-red:#cf2e2e;--wp--preset--color--luminous-vivid-orange:#ff6900;--wp--preset--color--luminous-vivid-amber:#fcb900;--wp--preset--color--light-green-cyan:#7bdcb5;--wp--preset--color--vivid-green-cyan:#00d084;--wp--preset--color--pale-cyan-blue:#8ed1fc;--wp--preset--color--vivid-cyan-blue:#0693e3;--wp--preset--color--vivid-purple:#9b51e0;--wp--preset--color--awb-color-1:rgba(255,255,255,1);--wp--preset--color--awb-color-2:rgba(246,246,246,1);--wp--preset--color--awb-color-3:rgba(235,234,234,1);--wp--preset--color--awb-color-4:rgba(224,222,222,1);--wp--preset--color--awb-color-5:rgba(116,116,116,1);--wp--preset--color--awb-color-6:rgba(26,128,182,1);--wp--preset--color--awb-color-7:rgba(51,60,78,1);--wp--preset--color--awb-color-8:rgba(51,51,51,1);--wp--preset--color--awb-color-custom-10:rgba(16,83,120,1);--wp--preset--color--awb-color-custom-11:rgba(59,175,191,1);--wp--preset--color--awb-color-custom-12:rgba(235,234,234,.8);--wp--preset--color--awb-color-custom-13:rgba(190,189,189,1);--wp--preset--color--awb-color-custom-14:rgba(232,232,232,1);--wp--preset--color--awb-color-custom-15:rgba(144,201,232,1);--wp--preset--color--awb-color-custom-16:rgba(90,171,214,1);--wp--preset--color--awb-color-custom-17:rgba(56,128,186,1);--wp--preset--color--awb-color-custom-18:rgba(160,206,78,1);--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple:linear-gradient(135deg,rgba(6,147,227,1) 0%,#9b51e0 100%);--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan:linear-gradient(135deg,#7adcb4 0%,#00d082 100%);--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange:linear-gradient(135deg,rgba(252,185,0,1) 0%,rgba(255,105,0,1) 100%);--wp--preset--gradient--luminous-vivid-orange-to-vivid-red:linear-gradient(135deg,rgba(255,105,0,1) 0%,#cf2e2e 100%);--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray:linear-gradient(135deg,#eee 0%,#a9b8c3 100%);--wp--preset--gradient--cool-to-warm-spectrum:linear-gradient(135deg,#4aeadc 0%,#9778d1 20%,#cf2aba 40%,#ee2c82 60%,#fb6962 80%,#fef84c 100%);--wp--preset--gradient--blush-light-purple:linear-gradient(135deg,#ffceec 0%,#9896f0 100%);--wp--preset--gradient--blush-bordeaux:linear-gradient(135deg,#fecda5 0%,#fe2d2d 50%,#6b003e 100%);--wp--preset--gradient--luminous-dusk:linear-gradient(135deg,#ffcb70 0%,#c751c0 50%,#4158d0 100%);--wp--preset--gradient--pale-ocean:linear-gradient(135deg,#fff5cb 0%,#b6e3d4 50%,#33a7b5 100%);--wp--preset--gradient--electric-grass:linear-gradient(135deg,#caf880 0%,#71ce7e 100%);--wp--preset--gradient--midnight:linear-gradient(135deg,#020381 0%,#2874fc 100%);--wp--preset--font-size--small:15px;--wp--preset--font-size--medium:20px;--wp--preset--font-size--large:30px;--wp--preset--font-size--x-large:42px;--wp--preset--font-size--normal:20px;--wp--preset--font-size--xlarge:40px;--wp--preset--font-size--huge:60px;--wp--preset--spacing--20:.44rem;--wp--preset--spacing--30:.67rem;--wp--preset--spacing--40:1rem;--wp--preset--spacing--50:1.5rem;--wp--preset--spacing--60:2.25rem;--wp--preset--spacing--70:3.38rem;--wp--preset--spacing--80:5.06rem;--wp--preset--shadow--natural:6px 6px 9px rgba(0,0,0,.2);--wp--preset--shadow--deep:12px 12px 50px rgba(0,0,0,.4);--wp--preset--shadow--sharp:6px 6px 0px rgba(0,0,0,.2);--wp--preset--shadow--outlined:6px 6px 0px -3px rgba(255,255,255,1),6px 6px rgba(0,0,0,1);--wp--preset--shadow--crisp:6px 6px 0px rgba(0,0,0,1);}:where(.is-layout-flex){gap:.5em;}:where(.is-layout-grid){gap:.5em;}body .is-layout-flow > .alignleft{float:left;margin-inline-start:0;margin-inline-end:2em;}body .is-layout-flow > .alignright{float:right;margin-inline-start:2em;margin-inline-end:0;}body .is-layout-flow > .aligncenter{margin-left:auto !important;margin-right:auto !important;}body .is-layout-constrained > .alignleft{float:left;margin-inline-start:0;margin-inline-end:2em;}body .is-layout-constrained > .alignright{float:right;margin-inline-start:2em;margin-inline-end:0;}body .is-layout-constrained > .aligncenter{margin-left:auto !important;margin-right:auto !important;}body .is-layout-constrained > :where(:not(.alignleft):not(.alignright):not(.alignfull)){max-width:var(--wp--style--global--content-size);margin-left:auto !important;margin-right:auto !important;}body .is-layout-constrained > .alignwide{max-width:var(--wp--style--global--wide-size);}body .is-layout-flex{display:flex;}body .is-layout-flex{flex-wrap:wrap;align-items:center;}body .is-layout-flex > *{margin:0;}body .is-layout-grid{display:grid;}body .is-layout-grid > *{margin:0;}:where(.wp-block-columns.is-layout-flex){gap:2em;}:where(.wp-block-columns.is-layout-grid){gap:2em;}:where(.wp-block-post-template.is-layout-flex){gap:1.25em;}:where(.wp-block-post-template.is-layout-grid){gap:1.25em;}.has-black-color{color:var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-color{color:var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-color{color:var(--wp--preset--color--white) !important;}.has-pale-pink-color{color:var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-color{color:var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-color{color:var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-color{color:var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-color{color:var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-color{color:var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-color{color:var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-color{color:var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-color{color:var(--wp--preset--color--vivid-purple) !important;}.has-black-background-color{background-color:var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-background-color{background-color:var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-background-color{background-color:var(--wp--preset--color--white) !important;}.has-pale-pink-background-color{background-color:var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-background-color{background-color:var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-background-color{background-color:var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-background-color{background-color:var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-background-color{background-color:var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-background-color{background-color:var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-background-color{background-color:var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-background-color{background-color:var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-background-color{background-color:var(--wp--preset--color--vivid-purple) !important;}.has-black-border-color{border-color:var(--wp--preset--color--black) !important;}.has-cyan-bluish-gray-border-color{border-color:var(--wp--preset--color--cyan-bluish-gray) !important;}.has-white-border-color{border-color:var(--wp--preset--color--white) !important;}.has-pale-pink-border-color{border-color:var(--wp--preset--color--pale-pink) !important;}.has-vivid-red-border-color{border-color:var(--wp--preset--color--vivid-red) !important;}.has-luminous-vivid-orange-border-color{border-color:var(--wp--preset--color--luminous-vivid-orange) !important;}.has-luminous-vivid-amber-border-color{border-color:var(--wp--preset--color--luminous-vivid-amber) !important;}.has-light-green-cyan-border-color{border-color:var(--wp--preset--color--light-green-cyan) !important;}.has-vivid-green-cyan-border-color{border-color:var(--wp--preset--color--vivid-green-cyan) !important;}.has-pale-cyan-blue-border-color{border-color:var(--wp--preset--color--pale-cyan-blue) !important;}.has-vivid-cyan-blue-border-color{border-color:var(--wp--preset--color--vivid-cyan-blue) !important;}.has-vivid-purple-border-color{border-color:var(--wp--preset--color--vivid-purple) !important;}.has-vivid-cyan-blue-to-vivid-purple-gradient-background{background:var(--wp--preset--gradient--vivid-cyan-blue-to-vivid-purple) !important;}.has-light-green-cyan-to-vivid-green-cyan-gradient-background{background:var(--wp--preset--gradient--light-green-cyan-to-vivid-green-cyan) !important;}.has-luminous-vivid-amber-to-luminous-vivid-orange-gradient-background{background:var(--wp--preset--gradient--luminous-vivid-amber-to-luminous-vivid-orange) !important;}.has-luminous-vivid-orange-to-vivid-red-gradient-background{background:var(--wp--preset--gradient--luminous-vivid-orange-to-vivid-red) !important;}.has-very-light-gray-to-cyan-bluish-gray-gradient-background{background:var(--wp--preset--gradient--very-light-gray-to-cyan-bluish-gray) !important;}.has-cool-to-warm-spectrum-gradient-background{background:var(--wp--preset--gradient--cool-to-warm-spectrum) !important;}.has-blush-light-purple-gradient-background{background:var(--wp--preset--gradient--blush-light-purple) !important;}.has-blush-bordeaux-gradient-background{background:var(--wp--preset--gradient--blush-bordeaux) !important;}.has-luminous-dusk-gradient-background{background:var(--wp--preset--gradient--luminous-dusk) !important;}.has-pale-ocean-gradient-background{background:var(--wp--preset--gradient--pale-ocean) !important;}.has-electric-grass-gradient-background{background:var(--wp--preset--gradient--electric-grass) !important;}.has-midnight-gradient-background{background:var(--wp--preset--gradient--midnight) !important;}.has-small-font-size{font-size:var(--wp--preset--font-size--small) !important;}.has-medium-font-size{font-size:var(--wp--preset--font-size--medium) !important;}.has-large-font-size{font-size:var(--wp--preset--font-size--large) !important;}.has-x-large-font-size{font-size:var(--wp--preset--font-size--x-large) !important;}.wp-block-navigation a:where(:not(.wp-element-button)){color:inherit;}:where(.wp-block-post-template.is-layout-flex){gap:1.25em;}:where(.wp-block-post-template.is-layout-grid){gap:1.25em;}:where(.wp-block-columns.is-layout-flex){gap:2em;}:where(.wp-block-columns.is-layout-grid){gap:2em;}.wp-block-pullquote{font-size:1.5em;line-height:1.6;}.wp-block-audio figcaption{color:#555;font-size:13px;text-align:center;}.is-dark-theme .wp-block-audio figcaption{color:rgba(255,255,255,.65);}.wp-block-audio{margin:0 0 1em;}.wp-block-code{border:1px solid #ccc;border-radius:4px;font-family:Menlo,Consolas,monaco,monospace;padding:.8em 1em;}.wp-block-embed figcaption{color:#555;font-size:13px;text-align:center;}.is-dark-theme .wp-block-embed figcaption{color:rgba(255,255,255,.65);}.wp-block-embed{margin:0 0 1em;}.blocks-gallery-caption{color:#555;font-size:13px;text-align:center;}.is-dark-theme .blocks-gallery-caption{color:rgba(255,255,255,.65);}.wp-block-image figcaption{color:#555;font-size:13px;text-align:center;}.is-dark-theme .wp-block-image figcaption{color:rgba(255,255,255,.65);}.wp-block-image{margin:0 0 1em;}.wp-block-pullquote{border-bottom:4px solid;border-top:4px solid;color:currentColor;margin-bottom:1.75em;}.wp-block-pullquote cite,.wp-block-pullquote footer,.wp-block-pullquote__citation{color:currentColor;font-size:.8125em;font-style:normal;text-transform:uppercase;}.wp-block-quote{border-left:.25em solid;margin:0 0 1.75em;padding-left:1em;}.wp-block-quote cite,.wp-block-quote footer{color:currentColor;font-size:.8125em;font-style:normal;position:relative;}.wp-block-quote.has-text-align-right{border-left:none;border-right:.25em solid;padding-left:0;padding-right:1em;}.wp-block-quote.has-text-align-center{border:none;padding-left:0;}.wp-block-quote.is-large,.wp-block-quote.is-style-large,.wp-block-quote.is-style-plain{border:none;}.wp-block-search .wp-block-search__label{font-weight:700;}.wp-block-search__button{border:1px solid #ccc;padding:.375em .625em;}:where(.wp-block-group.has-background){padding:1.25em 2.375em;}.wp-block-separator.has-css-opacity{opacity:.4;}.wp-block-separator{border:none;border-bottom:2px solid;margin-left:auto;margin-right:auto;}.wp-block-separator.has-alpha-channel-opacity{opacity:1;}.wp-block-separator:not(.is-style-wide):not(.is-style-dots){width:100px;}.wp-block-separator.has-background:not(.is-style-dots){border-bottom:none;height:1px;}.wp-block-separator.has-background:not(.is-style-wide):not(.is-style-dots){height:2px;}.wp-block-table{margin:0 0 1em;}.wp-block-table td,.wp-block-table th{word-break:normal;}.wp-block-table figcaption{color:#555;font-size:13px;text-align:center;}.is-dark-theme .wp-block-table figcaption{color:rgba(255,255,255,.65);}.wp-block-video figcaption{color:#555;font-size:13px;text-align:center;}.is-dark-theme .wp-block-video figcaption{color:rgba(255,255,255,.65);}.wp-block-video{margin:0 0 1em;}.wp-block-template-part.has-background{margin-bottom:0;margin-top:0;padding:1.25em 2.375em;}.wp-block-button__link{color:#fff;background-color:#32373c;border-radius:9999px;box-shadow:none;text-decoration:none;padding:calc(.667em + 2px) calc(1.333em + 2px);font-size:1.125em;}.wp-block-file__button{background:#32373c;color:#fff;text-decoration:none;}