Sample Employee Non-Tobacco User Affidavit

Sample Employee Non-Tobacco User Affidavit

This is a sample document that is optional and can be used at the discretion of the health care facility.

I declare that I and everyone in my family covered under the (hospital) medical plan are “Non-tobacco users”. “Non-tobacco use” means I and my covered family members have not used any cigarettes, pipes, cigars, chewing tobacco, snuff, or any other tobacco products regardless of the number of times, frequency or method of use, within the last 90 days immediately preceding this affidavit. I understand that if I or any of my covered family members uses a tobacco product at any time between the date this affidavit is signed and (specific date), I will no longer be eligible to be designated as “non-tobacco user” and must inform Human Resources.

If I and everyone in my family covered under the hospital’s medical plan stop using tobacco products for the 90 days preceding (inset date), I can sign an affidavit and request to be designated a non-tobacco user. Completed affidavits must be received in Human Resources by 5 p.m. on (insert date).

Additional opportunities to stop using tobacco products and request a non-tobacco user designation are available during 2007 by signing an affidavit by April 1, July 1, or October 1 signifying that I and my covered family members have not used any cigarettes, pipes, cigars, chewing tobacco, snuff, snus, electronic cigarettes, or any other tobacco products regardless of the number of times, frequency or method of use, in the previous 90 day period.

I understand that I, or any covered member of my family, may be tested for tobacco use at any time, and, if I falsely claim the non-tobacco user discount on my application for Medical Coverage or in this affidavit, that all medical claims submitted after the date of this affidavit that are related to tobacco use can be denied; the non-tobacco user status can be rescinded and; I may be subject to corrective action.

I, the applicant, have read the above and understand the penalties that may apply if my statements are false.

Printed Name:______Employee Number: ______

Signature:______Date: ______

PLEASE RETURN TO HUMAN RESOURCES BY [INSERT TIME] ON [INSERT DATE] TO KEEP DISCOUNTED NON-TOBACCO RATES FOR THE HEALTHCARE PLAN.