CareFirst Applicants

Transcription

1 Careirst Applicants Application Instructions for Careirst 1.Print all pages of the application including instructions 2.Complete all questions and sections of the application. 3.Select your preferred billing method. 4.Sign and date the application. 5. Complete the fax cover letter on the next page and fax to Annapolis Insurance Advisors for review along with the completed application. If you do not have access to a fax machine, send the completed application to Annapolis Insurance Advisors. IPORTANT: edical underwriting is a systematic process that insurers use to evaluate information about a health insurance applicant. An underwriter at Careirst carefully reviews the answers you provide to the health questions in your application. In addition, we may review past claims history on file, if applicable, and any medical reports completed by physicians. Based on this information we may approve the application at the requested rate or a higher rate, deny the request for coverage or deny coverage for a particular applicant. The review process typically takes 4-6 weeks. ail completed applications and check to: Annapolis Insurance Advisors Attn: New Enrollment 3 Church Circle Suite 161 Annapolis, D Annapolis Insurance Advisors will review your application for completeness and accuracy before we submit it to Careirst for processing. This may reduce the approval time because they cannot process unclear or incomplete applications until the missing information has been gathered. Please contact us if you have any questions regarding the application or the application process. You may reach us at or us at paul@paulmurphyannapolis.com. Norvax form #IN-1

2 Attention: Annapolis Insurance Advisors AX COVER LETTER (Please ignore this form if you do not have access to a fax machine.) Please AX this cover letter with the completed application to: Annapolis Insurance Advisors AX# Dear Annapolis Insurance Advisors, Please accept my completed application for submittal and contact me to confirm receipt of this application Name Date Time Please contact me at this phone number after you have reviewed my application for completeness and accuracy. I will contact Annapolis Insurance Advisors at to verify receipt of my application. I understand that Annapolis Insurance Advisors will not review this application until the following business day if I faxed this application after 5:00P or on a weekend I will send the original application as soon as I have been contacted by Annapolis Insurance Advisors with confirmation that my application has been received by fax and reviewed for completeness. I understand that the original signed application must still be mailed to Annapolis Insurance Advisors. I will mail the original signed application to : Annapolis Insurance Advisors Attn: New Enrollment 3 Church Circle Suite 161 Annapolis, D I will send the original application as soon as I have been contacted by Annapolis Insurance Advisors with confirmation that my application has been received by fax and reviewed for completeness. Norvax form #CS-1

3 Individual BluePreferred Health Savings Account (HSA) Plan Application OICE USE ONLY: ID #: CLASS/PLAN #: GROUP #: E DATE: (Virginia Residents) Group Hospitalization and edical Services, Inc. 840 irst Street, NE, Washington, DC INSTRUCTIONS 1. Please fill out all applicable spaces on this application. Print or type all information. 2. Sign and return this application in the postage-paid return envelope if provided, or mail to: Careirst BlueCross BlueShield Individual arket Division/RR ill Run Circle Owings ills, D Give careful attention to all questions in this application. Accurate, complete information is necessary before your application can be processed. If incomplete, the application will be returned and delay your coverage. Type of Enrollment (Check one) Underwritten Underwritten (irst choice) or HIPAA (Second choice) HIPAA 1. applicant information (The oldest applicant will be the Subscriber.) Last Name first Name Initial Social Security # Residence Address: (Number and Street, Apt. #) city and State Zip Code (9-digit, if known) Billing Address, if different from Residence Address: (Number and Street, Apt. #) City and State Zip Code (9-digit, if known) Date of Birth Sex arital Status Height Weight / / ale emale single married Partner Home Phone Work Phone Address ( ) 2. Coverage selection: (Check one) ( ) Individual - Provides coverage for one person Individual & Child(ren) - Provides coverage for an individual and eligible dependent(s) Individual & Adult - Provides coverage for two eligible adults amily - Provides coverage for two eligible adults and eligible dependent(s) 3. Enrolling amily member(s) Complete only if you select Individual & Child(ren), Individual & Adult or amily Coverage Last Name irst Name. I. Relationship Social Security # Date of Birth (o/day/yr) SEX HEIGHT (in.) Spouse/Partner Dependent 1 Dependent 2 Dependent 3 Dependent 4 or Broker Use Only: Name: SSN/Tax ID #: Careirst-Assigned ID#: Contracted Broker: Sub-Agent/Sub-Agency: Writing Agent: Paul urphy WEIGHT (lbs.) Careirst BlueCross BlueShield is the business name of Group Hospitalization and edical Services, Inc. and is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of Careirst of aryland, Inc. BHVVAAP (7/08) 1 CUT6722-1S (9/08)

4 4. COVERAGE LEVEL: Individual Deductible Coverage Level Individual Out-of-Pocket Limit Check one: (In-Network) (Out-of-Network) (In-Network) (Out-of-Network) (In-Network) (Out-of-Network) $1,200 $2,400 80% 60% $2,800 $5,000 $2,700 $5, % 80% $3,200 $6,400 ATERNITY BENEITS: Check this box if you wish to include benefits for maternity services (additional cost)... Yes VISION BENEITS: Check this box if you wish to include benefits for vision services (additional cost)... Yes 5. Other Insurance Information I YOU HAVE OTHER INSURANCE, AILURE TO COPLETE THIS SECTION WILL CAUSE SIGNIICANT DELAYS IN PROCESSING ANY CLAIS SUBITTED. 1. Is anyone listed on this application eligible for edicare? If yes, please provide the following: Name of family member(s) edicare No Effective Date 2. Is anyone listed on this application covered by other health insurance, including other Blue Cross and Blue Shield coverage? If yes, please provide the following: Name of family member(s) Insurance Company Policy Number and Type Effective Date If you are accepted, will your new Careirst BlueCross BlueShield coverage replace your existing policy? 3. Has anyone listed on this application been without health insurance for the past 12-months or longer? If yes, please list name(s): 6. hipaa eligibility information 1. Are any applicant(s) eligible (whether enrolled or not) for coverage under any group health benefits plan or employer sponsored health benefit plan? 2. Are any applicant(s) eligible or entitled (whether enrolled or not) for edicare, Part A or Part B? If entitled, please state the name(s) of the applicant(s) and the applicant s edicare Claim Number 3. Are any applicant(s) eligible (whether enrolled or not) for edicaid, or any similar state plan under Title XIX of the Social Security Act? 4. Are any applicant(s) currently covered under any other health benefit plan? Provide coverage information in Section 5 (Other Insurance Information), above. 5. Was the applicant s prior health benefits plan terminated because of nonpayment of premium or subscription charges by the applicant? 6. Was the applicant s prior health benefits plan terminated for reasons of fraudulent act or intentional misrepresentation by the applicant? 2

5 6. hipaa eligibility information (Continued) ederal law requires that a group health plan sponsored by an employer who regularly employs 20 or more employees offer employees and their families the opportunity for a temporary extension of health coverage called Continuation Coverage (or COBRA coverage). This Continuation Coverage is offered for a specific number of months depending on the applicant s situation. The employer or Plan Administrator will be able to tell an applicant(s) how many months of Continuation Coverage is available. 7. If the applicant(s) were offered this Continuation Coverage, did the applicant(s) refuse this coverage or elect to terminate this coverage before the end of the allowed Continuation Coverage period? INSTRUCTIONS: Applicants REQUIRED to Complete the Health Status Section of the Application: Any applicant who has not been covered under any health benefits plan for the past 63 days. Any applicant who answered any of the above questions in Section 6 (HIPAA Eligibility Information) with YES. Any applicant who wants to be considered for the Underwritten coverage only or for both the Underwritten coverage (first choice) and the HIPAA coverage (second choice). Applicants who are NOT Required to Complete the Health Status Section of the Application: Any applicant who submits a Certificate(s) of Coverage that states: 1) that the applicant has a total of 18-months or more of continuous creditable coverage; 2) whose most recent creditable coverage was under individual health insurance coverage, a group health plan, governmental plan, or church plan, or any health benefit plan offered in connection with these plans; and 3) the applicant answered all of the above questions in Section 6 (HIPAA Eligibility Information) with NO. Any applicant who submits a Certificate(s) of Coverage that states: 1) that the applicant has a total of 12-months or more of continuous creditable coverage; 2) whose most recent creditable coverage was under an individual health insurance policy which was nonrenewed by the health insurance issuer because the health insurance issuer is no longer offering any type of health insurance coverage in the individual market; and 3) the applicant answered all of the above questions in Section 5 (HIPAA Eligibility Information) with NO. NOTE: An applicant s prior insurer(s) or health plan(s) are required by federal law to provide a Certificate(s) of Coverage that indicates how many months the applicant has been continuously covered under creditable coverage, as defined under ederal and State law. Please attach all Certificate(s) of Coverage to this application. Retain a copy for your records. 7. HEAlTH EVALUATION PLEASE COPLETE SECTIONS A, B AND C. CHECK EACH ITE YES OR NO. Have you or any family member named in this application had a physical examination within the past five years? SECTION 7A If any person included in this application is presently using or has used medication or prescription drugs in the past 5 years, please provide the following information. Name of amily ember Illness or Condition edication Date of Last Treatment How often Taken Attending Physician Name and Address 3

6 7. HEAlTH evaluation (Continued) SECTION 7B To the best of your knowledge or belief, has any person named in this application had within the last five years, or does such person now have, any of the following: 1. Cancer, tumor or other growth (malignant or benign) Acquired Immune Deficiency Syndrome (AIDS) or Human Immunodeficiency Virus Seropositivity (Positive HIV test) Kidney stones, kidney or bladder condition, urinary frequency or burning Goiter, thyroid condition, diabetes Seizure disorder, central nervous system disorder, multiple sclerosis Substance abuse (drug or alcohol dependency, abuse or addiction) Use of illicit drugs Gall bladder condition, hernia, stomach or intestinal condition, ulcers, hemorrhoids, liver condition Cataract or other eye condition Tuberculosis, lung condition, asthma, bronchitis Arthritis, rheumatism, external deformity, amputation(s), back or spinal trouble, limb condition Heart condition, abnormal blood pressure (hypertension or hypotension), rheumatic fever, cerebrovascular accident (stroke) (emale) Irregular or excessive menstrual bleeding, reproductive system disorders, breast condition (emale) is currently pregnant; expected date of delivery: / / (ale) Prostate condition, reproductive system disorders Do you or your spouse/partner have infertility or any disorder related to infertility Have you or your spouse/partner received any treatment or diagnostic work-up related to infertility Have you been told that you have high or elevated cholesterol, lipids or triglycerides Outpatient counseling, any psychiatric or psychological counseling, or any nervous or mental disorder Sexually transmitted diseases Anemia, blood disorders Excluding physical examinations, consulted a physician, health care provider, or other individual or facility for medical or surgical treatment, advice, screening for any condition, or prescription medication for a medical condition NOT listed above in items 1-21? Had any known departure from good health not previously mentioned in this questionnaire for which treatment or advice may or may not have been sought?... NOTE: ALL QUESTIONS UST BE CHECKED YES OR NO Or your application will be returned. SECTION 7C If you have checked YES to any part of SECTION 7B, for each box checked, please provide complete information regarding diagnosis or condition, treatment (including all medications, hospitalizations, surgeries and diagnostic testing results) and dates. If more space is needed, attach a separate sheet of paper. Note: ailure to disclose conditions may result in voiding of membership and denial of benefits. Patient s irst Name Question Number Diagnosis or Condition Duration Dates Explain treatment including all medications, hospitalizations, surgery and diagnostic test results and physician s/hospital s name. Recovery (Check only one box) rom: ULL rom: ULL rom: ULL rom: ULL rom: ULL rom: ULL 4

7 8. Conditions of Enrollment Please Read This Section Carefully IT IS UNDERSTOOD AND AGREED THAT: A copy of this application is available to the Subscriber (or to a person authorized to act on his/her behalf) upon request, from Group Hospitalization and edical Services, Inc. doing business as Careirst BlueCross BlueShield (Careirst). This information is subject to verification. To do so I authorize any physician, hospital, pharmacy, pharmacy benefit manager or pharmacy related service organizations or any other medical or medically-related person or company to release my edical Information to Group Hospitalization and edical Services, Inc. doing business as Careirst BlueCross BlueShield (Careirst) or Careirst s vendors or representatives. I further authorize any vendor who receives edical Information from any physician, hospital, pharmacy, pharmacy benefit manager or pharmacy related service organizations or any other medical or medically-related person or company to release my edical Information to Careirst. I understand that my edical Information consists of any diagnoses, treatment, prescriptions from a pharmacy, or any other medically related information about me. I authorize Careirst to use my edical Information for underwriting and to determine my eligibility for insurance benefits. I understand this authorization will remain in effect for one year from the date signed. I understand that I have the right to cancel this authorization at any time, in writing, except to the extent that Careirst has already taken action in reliance on this authorization. I also understand that Careirst s Notice of Privacy Practices includes information pertaining to authorizations and to requirements of revocation. A copy of the Notice may be obtained by contacting the Careirst s Privacy Office. Careirst will not use or disclose the edical Information for any purposes other than those listed above except as may be required by law. Careirst is required to tell you by law that information disclosed pursuant to this authorization may be subject to re-disclosure and that under some limited circumstances will no longer be protected by federal privacy regulations. If Careirst determines that additional information is needed, I will receive an authorization to release that information. ailure to execute an authorization may result in the denial of my application for coverage. Additionally I understand that failure to complete any section of this application, including signing below, may delay the processing of my application. To the best of my knowledge and belief, all statements made on this application are complete, true and correctly recorded. They are representations that are made to induce the issuance of, and form part of the consideration for a Careirst policy. I understand that a medically underwritten policy is only issued under the conditions that the health of all persons named on the application remains as stated above. I also understand that failure to enter accurate, complete and updated medical information may result in the denial of all benefits, cancellation or voiding of my policy. I will update Careirst if there have been any changes in health concerning any person listed in this application that occurs prior to acceptance of this application by Careirst. By signing this application, I hereby authorize Careirst BlueCross BlueShield to disseminate and share non-health questionnaire information contained on this application with the Health Savings Account preferred bank(s) affiliated with Careirst BlueCross BlueShield. I understand that dissemination of information to any such bank is at my direction and with my full understanding. urther that dissemination of information on this application, excluding health questionnaire information, is necessary in order to effectuate the establishment of a Health Savings Account in my name with the bank. The authorization shall continue until my enrollment with Careirst BlueCross BlueShield terminates or at any time that I provide a written instruction to Careirst BlueCross BlueShield revoking this authorization or if this authorization terminates by operation of law. If you do not want information on this application shared with the Health Savings Account preferred bank(s) please check here. I YOU HAVE ANY QUESTIONS CONCERNING THE BENEITS AND SERVICES THAT ARE PROVIDED BY OR EXCLUDED UNDER THIS AGREEENT, PLEASE CONTACT A EBERSHIP SERVICES REPRESENTATIVE BEORE SIGNING THIS APPLICATION. An applicant or dependent whose Application is denied by Careirst due to medical underwriting may not submit a subsequent Application for enrollment within ninety (90) days of the denial. Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may have violated state law. Signature of Applicant 1:* X Date: Signature of Applicant 2: X Date: (Spouse/Partner) * Rates are based on the age of the Policy Holder (oldest applicant). NOTE: Applications submitted solely on behalf of applicants under the age of 18, where payment of premium is made by the parent or legal guardian, must be signed by the parent or legal guardian. Parent or Legal Guardian s Signature: X Date: OR OICE USE ONLY: Re-sign and re-date below only if box is checked. Signature of Applicant 1: X Date: Signature of Applicant 2: X Date: (Spouse/Partner) 5