The Methodist Hospital System Sample Initial Letter.pdf - ConSova

Dependent Verification FormPlease mail this completed and signed form and the requested verification documentation, in theenclosed postage-paid envelope by Month Day, Year to ensure that coverage continues for youreligible dependents.Please check the appropriate box: I have enclosed the requested documentation to verify the eligibility of my dependent(s). I have an ineligible dependent(s) and have noted the reason below. I understand that theircoverage will end as soon as administratively possible.Ineligible Dependent(s)If any of your dependent(s) are no longer eligible for medical or dental coverage, please providehis/her name(s) and the reason for ineligibility below. Coverage for ineligible dependents will endas soon as administratively possible.Ineligible Dependent NameIneligibility ReasonSignature of Employee:Date:By signing above, I certify and warrant to The Methodist Hospital System that all information on this Dependent VerificationForm is true, correct and current as of the date signed. I further understand that if I knowingly submit false information Imay be subject to disciplinary action up to and including termination of employment. I authorize The Methodist HospitalSystem and ConSova Corporation to contact any institution or organization to verify any and all documents provided foreligibility verification.Please mail this completed and signed form along with the requestedverification documentation.Caution: Form contains personalized encoded information. Do not share with others.