Spouse Attestation

Please take care to fill out this form accurately. Incorrect information will slow process time dramatically and/or result in a correction made at a later date.

First, please provide the information requested in the fields below.


Employee

Enrollment Type:
 

Next, please select one of the response options below regarding your primary care.

Please note that Preferred Primary Care teams are part of the following organizations: 

Blue Hill Hospital · CA Dean · Eastern Maine Medical Center· Inland Hospital · Maine Coast Hospital· Mercy Hospital · Sebasticook Valley Hospital · AR Gould Hospital · Mayo Regional Hospital · MDI Hospital · Northern Maine Medical Center · InterMed · Martin’s Point · Newport Family Practice

Selection:



Exception:


 

Please review the following information and complete the agreement.

__ I do hereby attest that the information I provided above is true and correct.
__ I understand that knowingly making a false statement is a violation of the Northern Light Health Code of Conduct, and as such may lead to discipline, up to and including termination of employment when deemed appropriate.
__ I understand that submitting this disclosure form is considered my electronic signature and is a legal document.

Click the “Submit Attestation” button below.

A copy of your submission will be sent to the email address indicated above – please double check that you typed it in correctly. Please retain your emailed copy for your records.