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AveNew Total Health

Confidential MEC Opt Out Form
Name*

First NameLast Name
Employer*
Date of Birth*

MonthDayYear
Date
Gender*

FemaleMale
Why the Insurance Form Only Lists “Male” & “Female”

Our insurance carrier currently requires gender to be reported as male or female because their systems are tied to federal reporting standards used by the IRS, CMS, and Social Security Administration. These agencies still process health coverage data using a binary gender field for eligibility, premium calculations, and coordination of benefits.

This is not a reflection of individual identity—it is simply a technical requirement based on how insurance data is matched and verified in national databases. Employees may select the option that most closely aligns with their legal or Social Security records to ensure their coverage is processed correctly.
Offer of Coverage
I understand that my employer (“the Company”) offers a Minimum Essential Coverage (MEC) health plan to eligible employees to help meet federal requirements for health coverage. I acknowledge that I have been given an opportunity to enroll in the Company’s MEC plan from my date of hire to November 30, 2026.*

Yes, I acknowledge that I have been given an opportunity to enroll in the Company’s MEC plan from my date of hire to November 30, 2026.No, I have not been offered an opportunity to enroll.
Waiver of MEC Coverage
By signing this form, I voluntarily decline (waive) enrollment in the Company’s MEC plan from today through November 30, 2026. I can only join the plan between today and November 30, 2026, if I have a qualifying event.
Reason for Waiver (check one):*

I am covered under a spouse’s employer-sponsored planI am covered under a parent’s employer-sponsored planI am covered under another employer-sponsored planI am covered under Medicare / Medical / VAI have individual coverage (on or off the Exchange/Marketplace)Other
Social Security Number (Confidential)*
123456789
Your Signature*

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Privacy & Security Notice

AveNew Total Health collects your Social Security Number (SSN) solely for the purpose of processing your health insurance waiver with the carrier's third-party administrator, as required for accurate enrollment, reporting, and compliance with federal law.

Your SSN will be:
- Used only for benefits administration and not for any employment-related decisions;
- Transmitted and stored securely in accordance with federal and state data-privacy requirements;
- Shared only with our licensed third-party administrator, who is contractually obligated to protect your information under HIPAA, data-security, and confidentiality standards;
- Accessed only by authorized personnel who require it to perform their job duties.
Your information will not be sold, used for marketing, or disclosed to any other party except as required by law.

If you have questions about how your information is protected, you may contact Human Resources.
AveNew Total Health is brought to you by AveNew Solutions Insurance Services

CA License #0N14021
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AveNew Total Health

Offer of Coverage

Waiver of MEC Coverage