26 LEGAL NOTICES I BENEFITS GUIDE LEGAL NOTICES HIPAA Special Enrollment Notice If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or gr oup health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependents lose eligibility fo r that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request en rol lment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other cov erage). In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, adoption, or pla cem ent for adoption. If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or b eco me eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must req ues t enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistan ce subsidy. To request special enrollment or to obtain more information about the plan's special enrollment provisions, contact the plan adm inistrator at [insert contact information] .