This notice describes how medical information about you may be used and disclosed and how you can get access to this information. The privacy of your information is important to us. Please review it carefully.
This is the Model Notice for COBRA Continuation Subsidy under the American Rescue Plan [ARP] Act of 2021. Employers please note that information for qualified beneficiaries must be completed.
ET-2311
Form
Active Employee /
Local Employer /
State Employer