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University System of Georgia Tobacco Use Certification Form v1

Policy and Definition of Tobacco User
In March 2014, the Board of Regents adopted to make USG 100% tobacco and smoke-free effective October 1, 2014. Tobacco and smoke-free campus policy
We define "Tobacco Products" as cigarettes, cigars, pipes, all forms of smokeless tobacco, clove cigarettes and any other smoking devices that use tobacco, such as hookahs, or simulate the use of tobacco, such as electronic cigarettes. USG considers a “Tobacco User” as someone who has used tobacco products within the past three consecutive months.

HIPAA and Privacy Standards
The USG maintains information provided in accordance with the privacy standards of the Health Insurance Portability and Accountability Act (HIPAA) to help manage your benefits. If you have questions about your information or believe that information provided to USG may be incorrect, please notify USG-Tobacco Free at USG-TobaccoFree@usg.edu.
I understand this certification is made in connection with a tobacco premium differential program required by the University System of Georgia and that my certification is intended to qualify as a reasonable alternative standard as required for outcomes-based wellness programs in accordance with the Patient Protection and Affordable Care Act (ACA) and HIPAA.*

Reasonable Alternative
If it is unreasonably difficult due to a health factor for you to meet the requirements under this program, or if it is medically inadvisable for you to attempt to meet the requirements of this program, notify USG-Tobacco Free at USG-TobaccoFree@usg.edu and we will make available a reasonable alternative standard for you to avoid the surcharge. For example, if a physician for nicotine addiction is currently treating you, we may request an affidavit from your physician and provide a reasonable alternative to incurring the surcharge.

Certification and Ethics Policy
Please be advised that when you certify your tobacco use, you are attesting that the information is true and correct to the best of your knowledge.  USG expects employees to uphold the highest standards of intellectual honesty and integrity in compliance with the USG Ethics policy, and therefore, you should respond honestly in regards to your tobacco use status. 
If you knowingly and willfully make a false or fraudulent statement to the University System of Georgia regarding your insurance coverage, including your status as a tobacco user, you may be subject to criminal prosecution.  Under state law (at O.C.G.A Section 16-10-20), if you are convicted, you shall be punished by a fine of not more than $1,000.00 or by imprisonment for not less than one nor more than five years, or both.

*See ACA and HIPAA wellness program guidelines, 26 CFR § 54.9802–1