How to Fill Out the San Francisco HCSO Employee Voluntary Waiver Form

The San Francisco HCSO Employee Voluntary Waiver Form is the two-page document the Office of Labor Standards Enforcement (OLSE) uses to let a covered employee opt out of their employer’s Health Care Security Ordinance spending obligation when they already receive health care through another employer. You download the current version from the OLSE’s HCSO page on sf.gov, fill in both pages, sign it voluntarily, and hand it to your employer with proof of your outside coverage.¹ The waiver lasts one year and you can cancel it in writing at any time.²

Before You Sign: Do You Actually Qualify?

You can sign the waiver only if you currently receive health care services through another employer. That means a plan provided through your own second job, or through the workplace of your spouse, domestic partner, or parent.² Coverage you bought yourself on the individual market, a Covered California plan, or a government program like Medi-Cal does not count, because none of those are employer-provided.

Signing has to be your choice. The form itself warns that it is unlawful for your employer to pressure you into waiving, and you should never feel obligated to sign.² If you don’t have qualifying outside coverage, or you do but you’d rather keep the HCSO expenditures your employer makes on your behalf, don’t sign.

Check That You Have Both Pages

The form is two pages, and the top of page one warns in bold: if you did not receive both pages, do not sign.² Confirm the complete document is in front of you before you fill in anything.

Filling Out Page One

Page one covers your employer’s information: the name of the San Francisco company whose HCSO obligation you are waiving, along with the address, a contact person, phone number, and email. Your employer typically completes this section before handing the form to you.

Filling Out Page Two

Page two is where you do most of the work. You will provide:

Your legal name as the employee signing the waiver.
The name of the other employer providing your health care services.
The name of the person listed as the primary enrollee on that plan — this may be you, your spouse, your domestic partner, or your parent.
Your relationship to the enrollee: check whether you are the primary enrollee yourself, a child, or a spouse or domestic partner.
The type of benefit and the name of the insurance provider or benefits administrator.
The effective date of the waiver.
Your signature and today’s date.

The effective date trips people up. It is the date your waiver begins, not the date your outside coverage started. It cannot be earlier than the day you sign, and it must fall within four months of the signing date.² If you want the waiver to apply right away, write today’s date. If you want it to start later — the beginning of next quarter, for example — pick a date within that four-month window.

Attach Proof of Your Other Coverage

The form requires you to give your employer proof of your health care services from the other employer.² A copy of your insurance card, a benefits enrollment confirmation, or a similar document works. Have it ready when you submit the signed form so your employer isn’t chasing you for documentation later.

Submit the Form and Keep a Copy

Hand the completed, signed form to your employer. Both you and your employer should keep a copy.² Your copy is what protects you if a question comes up later about whether the waiver was in force during a given pay period.

The Waiver Lasts One Year

A signed waiver is good for one year from the date of your signature. After that it expires automatically, and your employer has to obtain a new signed form from you each year you want to keep waiving.² If no renewal is signed, the employer must resume making HCSO health care expenditures on your behalf for the hours you work going forward.

The annual cycle doubles as a yearly check on whether your outside coverage is still active. A spouse switching jobs or a parent retiring can quietly end your qualifying coverage, and the renewal catches that.

How to Revoke a Signed Waiver

You can cancel the waiver at any time, and you do not need to give a reason. The revocation must be in writing, and it takes effect as soon as your employer receives it.² The form has a revocation section at the bottom of page two with the statement: “I no longer wish to give up my right to health care expenditures made on my behalf by my employer.”

Revoke promptly if you lose your outside coverage. Until the revocation reaches your employer, the waiver stays in effect and your San Francisco employer has no obligation to spend anything on your health care under the HCSO.

What You’re Giving Up When You Sign

The HCSO requires covered employers to spend a minimum dollar amount per hour worked on health care for each covered employee, with the rates published each year by the OLSE.¹ Those expenditures can take the form of insurance premiums, contributions to a health reimbursement arrangement, or payments into the SF City Option program. A valid waiver on file relieves your employer of that spending obligation for you during the waiver period, so signing is a real tradeoff. It makes sense when your outside coverage is solid; it stops making sense the moment that coverage is in doubt.

1
SF.gov. Health Care Security Ordinance
2
San Francisco Office of Labor Standards Enforcement. Health Care Security Ordinance Employee Voluntary Waiver Form