Tobacco Free Attestation

HealthChoice Tobacco-Free Attestation

Welcome to the HealthChoice Tobacco-Free Attestation.

To begin, please enter your information below. Required fields marked with *

If you need to locate your completed attestation, please re-enter your information below and select Continue.

Please enter your information exactly the way it is displayed on your HealthChoice Card.

First *

First name is required.

Last *

Last name is required.

Suffix

Date of Birth *

Date of birth is required and must be between 1900 and the current date.

SSN *

XXX-XX

Enter exactly 4 digits for SSN.

Employer