OLSE Regulations Implementing the Employer Spending Requirement of the San Francisco Health Care Security Ordinance (HCSO)

APPENDIX A: VOLUNTARY WAIVER FORM

EMPLOYEE VOLUNTARY WAIVER FORM

Effective 2008, San Francisco law requires your employer to make health care expenditures on your behalf. A health care

expenditure is an amount of money paid by your employer to you or to a third party for the purpose of providing you with access to

health care services. For example, your employer may:

• make payments to enroll you in a health insurance program,

• reimburse you for the costs of health care services you get on your own,

partner, or child of a person employed by that employer. To support a waiver request, your employer must obtain a new signed

Voluntary Waiver Form from you each year, updated as necessary to reflect any changes to the information provided.

Even if you receive health care services through another employer, you are entitled to receive health care services from this

employer. If you sign this form, your employer may stop making a mandatory health care expenditure to you or on your behalf. If

you want your employer to provide you with access to health care services, do not sign this form. It is illegal for your employer to

force or to pressure you to sign this form.

You have the right to cancel or revoke this voluntary waiver at any time. Your revocation must be submitted in writing. If you

revoke this waiver, your employer will be required to make health care expenditures to you or on your behalf.

I hereby certify that I receive health care services through another employer or through my spouse, domestic partner, or parent(s), as

indicated below:

If you receive health care services through another employer whom you work for and wish to provide a waiver to the

employer listed above, please provide the information below:

Name of Employer Providing Health Care Services: Type of Coverage Provided to You:

____________________________________________ □ health insurance (provide name of provider below)

Employer Address: ____________________________ ________________________________________________

Employer Contact Person: ______________________ □ SF Health Access Program/Healthy San Francisco

____________________________________________ □ health insurance (provide name of provider below)

His/Her Relationship to You: ____________________ ________________________________________________

Name of His/Her Employer _____________________ □ SF Health Access Program/Healthy San Francisco

His/Her Employer Address: _____________________ □ reimbursement/direct payment of health care expenses

Employer Contact Person: ______________________ □ other (describe) _________________________________

Employer Telephone No.: ______________________

I hereby waive the right to the health care expenditures described above, made to me or my behalf by the employer listed above.

Complete this section ONLY if you wish to revoke a Voluntary Waiver Form that you have signed and provided to your employer.

If you wish to waive your right to health care expenditures made to you or on your behalf by my employer, do NOT complete the

portion below.