In-Service Form First Name: (required 必填)Last Name: (required 必填)Aide Code: (required 必填)Date of Birth : (required 必填)SSN: (OPTIONAL)Address: (OPTIONAL)Waiving Health Coverage: (required 必填)—請選取選項—本人作為配偶或受撫養人得到其他團體醫療計劃保障 I am covered under another group plan as a spouse or dependent我現有醫療補助，聯邦醫療保險或退伍軍人計劃的保障 I am covered by Medicaid, Medicare, or Veterans Program我現有第二雇主所提供的醫療保險計劃的保護 I am covered under a health insurance plan sponsored by second employer我現有非團體, 個人或私人醫療保健計劃 I am covered through a non-group, individual or private health care plan not offered through my employer我目前不希望參加任何醫療保健福利（我完全拒絕了醫療保險） I don’t wish to participate in health care benefits at this time (I am declining health insurance entirely)Initials (First & Last Name) : (required 必填)Signature / 簽名: (required 必填)
