Form Hca 50 224 – Fill Out and Use This PDF

Form Hca 50 224 is a document with encompassing significance in the healthcare industry. It acts as a brief boilerplate guide for Direct Supervision Clinical Support Establishments and documents their internal medication regulations for Advanced Practice Registered Nurses. Beyond this specific purpose, Form Hca 50 224 provides additional points of information around patient rights, safe medication usage and practice schemes globally recognised by governing nurses’ associations across the world. Its contents ultimately serve to protect licenced nurses while raising standards of medical supervision delivered at such establishments. With Form Hca 50 224, multiple stakeholders can benefit from validating higher safety limits when addressing prescription concerns at these types of healthcare environments.

Form Hca 50 224 PDF Details

As a business owner, you are responsible for completing and filing certain government forms. One such form is Form Hca 50 224. This article will provide an overview of what this form is and how to complete it. Completing this form accurately and on time is critical, as it can impact your business's tax status. If you have any questions about the form or need assistance filing it, please contact your accountant or tax professional. Thank you for your time!

Question	Answer
Form Name	Form Hca 50 224
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	50 224 mchenry county illinois registration of domestic partnership form

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See details on

Attestations Worksheet.

Step One.

Premium Surcharge Attestation Form

Submit this form no later than 31 days (for employees) or 60 days (for all other subscribers who need to attest) from the date you become eligible for benefits to report whether the tobacco use and spouse or domestic partner coverage premium surcharges apply to you.

Section 1: Tobacco use premium surcharge

A monthly $25-per-account surcharge will be required in addition to your premium if you or a family member on your PEBB medical coverage uses a tobacco product. The surcharge will not apply if you and all family members ages 18 and older who use tobacco products are enrolled in your PEBB medical plan’s tobacco cessation program, or if children ages 17 and younger who use tobacco products access

information and resources at teen.smokefree.gov.

Tobacco use is defined as any use of tobacco products within the past two months. It does not include the religious or ceremonial use of tobacco.

Type or print clearly in black ink. List yourself and each family					Has this person used
					tobacco products in the
member you enroll on your PEBB medical coverage.					tobacco products in the
Select the “Yes” or “No” checkbox to attest for each family member,						last two months?

					Yes		No
regardless of age.					Yes		No
							Or he or she has used
(To list more family members, attach additional copies of this form.)							the tobacco cessation
							resources noted above.

	First name	Middle	Last name	Last four digits of
	First name	initial	Last name	Social Security no.
		initial		Social Security no.
YOU:

Family
member:

Family
member:

Family
member:

Family
member:

Family
member:

Family
member:

Family
member:

Family
member:

Family
member:

Family
member:

If you check “YES” or leave the checkboxes blank for yourself or any family member(s) listed above, you will pay the monthly $25 surcharge.

HCA 50-224 (9/14)

Page 1 of 2

Section 2: Spouse or domestic partner coverage premium surcharge

Complete this only if you enroll a spouse or domestic partner on your PEBB medical coverage.

A $50-per-month surcharge will be required in addition to your premium if you have a spouse or domestic partner enrolled on your PEBB medical coverage, and your spouse or domestic partner has chosen not to enroll in medical coverage through his or her employer that is comparable to Uniform Medical Plan (UMP) Classic.

See if this surcharge applies to you on the Attestations Worksheet: Step Two.

Does the spouse or domestic partner coverage surcharge apply to you?

Yes

I used the Attestations Worksheet: Step Two, and completed the Spousal Plan Calculator online.

Find the Spousal Plan Calculator

(electronic and paper versions) at www.hca.wa.gov/pebb .

I used the Attestations Worksheet: Step Two (and, if needed, completed the Spousal Plan Calculator online).

Employer or PEBB Program to determine

I used the Attestations Worksheet: Step Two, and am completing and submitting a paper Spousal Plan Calculator so my employer (for employees) or the PEBB Program (for all other subscribers) can determine whether my spouse’s or domestic partner’s employer-based group medical insurance is comparable to UMP Classic.

If you enroll a spouse or domestic partner on your PEBB medical coverage and you check “YES” or leave the checkboxes above blank, you will pay the monthly $50 surcharge.

Section 3: Signature

By signing this form, I declare that the information I have provided is true, complete, and correct. If it isn’t, or if I do not provide timely, updated information, I will owe surcharges to the PEBB Program. This form replaces all Premium Surcharge Attestation Forms and electronic surcharge attestations previously submitted.

HCA’s Privacy Notice: We will keep your information private as allowed by law. To see our Privacy Notice, go

to www.hca.wa.gov/pebb.

Name (print) ____________________________________	Last four digits of Social Security number __________
Signature _______________________________________	Date _________________________________________

Agency name ___________________________________________________________________________________

(employees only)

Please sign and date this form.

If you’re:

Return it to:

An employee

Any other subscriber

Your personnel, payroll, or benefits office, with your enrollment form.

PEBB Program

Washington State Health Care Authority

P.O. Box 42684

Olympia, WA 98504-2684

or fax to: 360-725-0771

Attach your printed Spousal Plan Calculator (if needed).

Page 2 of 2

How to Edit Form Hca 50 224 Online for Free

If you want to fill out Form Hca 50 224, you don't need to download any applications - simply try using our PDF editor. Our editor is continually evolving to provide the very best user experience attainable, and that's thanks to our resolve for continual improvement and listening closely to feedback from customers. Here is what you will need to do to begin:

Step 1: Press the "Get Form" button at the top of this page to get into our tool.

Step 2: With our advanced PDF editor, you can accomplish more than simply fill in forms. Try each of the functions and make your documents look sublime with customized textual content put in, or optimize the file's original content to excellence - all comes along with an ability to add almost any images and sign the PDF off.

Completing this form requires care for details. Make certain every blank is done properly.

1. It's important to complete the Form Hca 50 224 accurately, therefore be mindful when filling out the areas containing these fields:

Part no. 1 for filling out Form Hca 50 224

2. Soon after filling in this step, go to the next stage and enter the necessary particulars in these blanks - Family member, Family member, Family member, Family member, Family member, Family member, If you check YES or leave the, HCA, and Page of.

Guidelines on how to fill out Form Hca 50 224 stage 2

3. Completing Does the spouse or domestic, Yes, I used the Attestations Worksheet, Find the Spousal Plan Calculator, I used the Attestations Worksheet, Employer or PEBB Program to, I used the Attestations Worksheet, If you enroll a spouse or domestic, Section Signature, and By signing this form I declare is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

As to I used the Attestations Worksheet and I used the Attestations Worksheet, make certain you get them right here. The two of these are the most significant ones in this PDF.

4. All set to fill out this fourth section! Here you'll get all these HCAs Privacy Notice We will keep, Name print Last four digits of, Signature Date, Agency name employees only, Please sign and date this form, If youre, An employee, Any other subscriber, Return it to, Your personnel payroll or benefits, PEBB Program Washington State, and Attach your printed Spousal Plan form blanks to fill in.

PEBB Program Washington State, Your personnel payroll or benefits, and Agency name employees only of Form Hca 50 224

Step 3: Soon after rereading the fields, hit "Done" and you're all set! Get hold of your Form Hca 50 224 when you register at FormsPal for a 7-day free trial. Quickly view the pdf file in your FormsPal cabinet, together with any modifications and adjustments being all kept! FormsPal is invested in the personal privacy of our users; we make certain that all personal information entered into our tool stays confidential.

Form Hca 50 224 – Fill Out and Use This PDF

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