Form

This form is for account administrators only. Please do not share with anyone not already designated as an admin with Take Command.

Use this form to identify employees that have chosen not to participate in your Individual Coverage Health Reimbursement Arrangement (ICHRA) or Qualified Small Employer HRA (QSEHRA).

Please note: According to IRS Guidelines, employees must be provided notice of their ICHRA or QSEHRA. We generate these notices for each employee that is on your Employee Roster on the Take Command Health portal.

It is strongly recommended that you encourage employees to log-in and review their notices in the portal. This allows us to certify they have seen the required notices in the event of an audit. It will also allow us to collect the necessary data needed for your End of Year reporting. Employees that do not wish to participate can choose to waive the benefit in the portal.

We recognize sometimes it is difficult to get employees to take action and waive on their own. As an administrator, if you are confident you have delivered the required ICHRA or QSEHRA information to an employee and are confident they will choose not to participate (we recommend you collect something in writing or an email from them), then you can use this form to manually opt them out of the HRA. We will then update the employee's status to "not participating" in your portal and remove them from your monthly invoice. To guarantee that your waiver is processed before the next billing invoice is run, please submit your waiver request by the 24th of each month.

If you have any further questions, please reach out to the Client Success Services team at clientsuccess@takecommandhealth.com.

Thank you!

Company Admin Name*

Company Admin e-mail*

Company name*

How many employees are being waived on this form?*

What benefit year are you submitting the waiver for?*

Individual Employee Waiver Information

To waive an individual employee's coverage, please complete the section below. To waive multiple employees you may submit this section multiple times OR use the bulk upload section below.

Employee Name

Employee E-mail Address

Waive reasons

Bulk Upload Waiver

To waive multiple employees at once please download this template and upload in this section.

File upload