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.
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(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.
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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.
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