Tobacco Affidavit – Fill Out and Use This PDF

Tobacco Affidavit

You may complete this affidavit to notify PEIA if your tobacco status changes. Please mark which members of the family (if any) use tobacco and sign the affidavit. If none of the people enrolled on your health coverage uses tobacco you will receive any available discount on your health premiums. If the policyholder does not use tobacco, he or she will receive a discount on any Optional Life Insurance premiums.

I certify that the above information is true and correct. I further certify that if this information changes I will notify the plan of the change in writing. I acknowledge by signing this form that WVPEIA or its agents have access to my medical records to check my tobacco use status. I understand that providing false information on this form is illegal and that those who provide false information may be prosecuted. I hereby consent, for myself and my covered dependents, to the release to PEIA of all medical and prescription drug information needed to process claims, determine coverage, review utilization, investigate complaints, assess quality of care, evaluate plan performance or any other process involved in my treatment, payment of claims or health care operations.

Policyholder Signature ________________________________________________ Date __________________

Active Employees: Return this form to your Benefit Coordinator for completion of the Agency portion below.

Retired Employees: Mail the affidavit directly to PEIA, Attention: Open Enrollment Unit, 601 57TH ST., SE, SUITE 2, CHArleston, WV 25304-2345.