Tobacco Surcharge Removal Request If you have discontinued the use of tobacco, you may complete this form to request removal of the Tobacco Surcharge on your Qualified Health Plan (QHP). Only use black or blue ink. To request removal of the Tobacco Surcharge, please complete this form in its entirety. If you have any questions while completing this form, please contact the Nevada Health Link Customer Contact Center at 1-855-7NVLINK (1-855-7685465). Print clearly in all CAPs. Do NOT use gel, pencil or other color inks. Print your responses clearly within the provided spaces and fill in circles completely. Tobacco Surcharge Removal Request Form Examples: AB C D E F GH I J K 12345678 Yes No Enrollee/Applicant's Request 1) Exchange ID Number (from notice or invoice) 2) Date of Last Use of Tobacco M M D D Y Y Y Y 3) Additional comments: Continued on next page. Need help with your request? Call 1-855-768-5465 or visit us online at www.nevadahe al thli nk.com. Page 1 of 3 (Continued) Appeals Request Form Tobacco Surcharge Removal Request Form About the Enrollee/Applicant Filing the Request 4) First Name — Enrollee/Applicant MI Last Name — Enrollee/Applicant Suffix 5) Mailing Address Information — Enrollee/Applicant Suite/Apartment Number City State Zip Code (Continued) Tobacco Surcharge Removal Request Form 6) Date of Birth — Enrollee/Applicant M M D D Y Y Y Y 7) Email — Enrollee/Applicant @ 8) Primary Phone Number — Enrollee/Applicant – – Ext.: Home Work Mobile Home Work Mobile Secondary Phone Number (Optional) — Enrollee/Applicant – – Ext.: Continued on next page. Need help with your request? Call 1-855-768-5465 or visit us online at www.nevadahe al thli nk.com. Page 2 of 3 Tobacco Surcharge Removal Request Form D Please Read and Sign this Acknowledgement By signing below, I agree that I have provided true information regarding my Tobacco Use, and that I authorize Nevada Health Link to contact me in order to process this request. Date Signed Signature of the Person Submitting this Request M M D D Y Y Y Y Print the Name of the Person or Authorized Representative who has signed above: First Name MI Last Name Suffix Submit your completed, signed Tobacco Surcharge Removal Request. By Mail: Nevada Health Link PO BOX 97138 Las Vegas, NV 89193 By Fax: 1-855-868-5465 By Email: [email protected] (Continued) Tobacco Surcharge Removal Request Form Submitting Your Request Need help with your request? Call 1-855-768-5465 or visit us online at www.nevadahe al thli nk.com. Page 3 of 3
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