APPLICATION AND CHANGE FORM INDIVIDUAL/FAMILY COVERAGE New Policy Policy Change COBRA

Transcription

1 APPLICATION AND CHANGE FORM INDIVIDUAL/FAMILY COVERAGE New Policy Policy Change COBRA A. COVERAGE REQUESTED Self Only Self + Spouse or Domestic Partner Self + Child(ren) Family B. REASON FOR APPLICATION Please check one and include the effective date, as applicable: New Coverage Dependent Addition Open Enrollment Newborn/Adoption /Address Change Spouse Other: Dependent Deletion Dependent Age-Out Divorce Military Leave Court Order Loss of Coverage COBRA* Other Effective : Qualifying Event : *If you checked the Cobra box: Original Qualifying Event Last Day of Coverage Qualifying Event: C. APPLICANT INFORMATION REQUESTED EFFECTIVE DATE OF COVERAGE: Requesting an effective date does not guarantee that date of coverage. Coverage is not effective until it is approved and you are notified in writing. Applicant INTERNAL USE ONLY Actual Effective : Policy # Social Security Number Marital Status Single Domestic Partnership Married Divorced/Widowed Legally Separated Permanent Address City Address County State Zip Code Primary Phone # Alternate Phone # Primary Language (if other than English): Spanish (Español) Navajo (Dine) Chinese ( 漢字 ) Tagalog (Tagalog) First, MI (and Last, if different) Social Security Number Birth Gender Tobacco User 1 Self M F Y N Spouse M F Y N Domestic Partner 2 M F Y N 1 Definition the legal use (other than religious or ceremonial) of any tobacco product on average four or more times per week within no longer than the last six months. 2 Refer to Section H, Number 8, Terms and Conditions, for domestic partnership eligibility requirements.

2 D. OTHER COVERAGE Please indicate for each person listed on this application any health care coverage, Medicaid, or Medicare currently in effect. This will be used to determine if benefits will be coordinated. If no health coverage is in effect, indicate NONE. If coverage is provided for a dependent from a previous marriage or relationship, please attach a copy of the documentation that shows who is responsible for the dependent s health coverage so that the insurer can determine whose coverage is primary. Applicant: Spouse/Domestic Partner: Dependent of Individual Coverage Type/Insurer s of Coverage (MM/YY) Will Coverage Continue? (Y/N) E. WAIVER OF COVERAGE This section must be completed when waiving coverage for yourself, your spouse or domestic partner, or any dependent(s). INDIVIDUALS WAIVING COVERAGE of Individual Waiving Coverage Reason for Waiving Coverage WAIVER ACKNOWLEDGEMENT I understand that by listing myself, my spouse or any dependent in this section, I am choosing not to have that person(s) covered under the policy. In waiving coverage, I am aware that waiving individuals (including myself, if applicable) may not enroll until my policy s anniversary, unless the waiving individual qualifies for a Special Enrollment Period. F. PRODUCT SELECTION Please check one: G S B6000-DC G1000-DC S2000-DC Other: Important: In connection with your purchase of InHealth coverage, you are required to also purchase pediatric dental coverage from our preferred dental carrier, Delta Dental of Ohio, unless you have separately purchased an exchangecertified stand-alone dental plan. If you have already purchased an exchange-certified stand-alone dental plan, please check the box below and provide the documentation requested. Check this box if you certify you have purchased an exchange certified stand-alone dental plan and you have attached to this form, or will submit to us, documentation of such coverage. CHM_IFP2014_APP P a g e 2

3 G. BILLING INFORMATION CHOOSE ONE: HOME Receive monthly premium billings In case of insufficient funds, a $35 returned item fee will be applied. FINANCIAL INSTITUTION Monthly automatic premium payments If you wish to be billed through your financial institution, please complete the following authorization: I authorize Coordinated Health Mutual, Inc. (d/b/a/ InHealth Mutual) to initiate premium payments from my account. The authorization will remain in effect until Coordinated Health Mutual, Inc. and my financial institution have received written notification from me within a reasonable time period to allow termination of the payment arrangement. Premiums are to be deducted from: Checking Savings (Please note: Not all Financial Institutions allow deductions from a savings account. Please verify this information with your financial institution.) In case of insufficient funds, a $35 returned item fee will be applied. and Branch of Bank/Financial Institution Account Number Address Account Holder s City State Zip Code Transit Routing Number Account Holder s Signature Please attach a voided check for checking account or a deposit slip for savings account in order for our office to verify the bank information. CREDIT CARD Have monthly premium billed to credit card If you wished to be billed through your credit card, please complete the following authorization: Mastercard Visa Discover American Express Cardholder Card Number CSC The 3 digit code on back of your credit card Bank (if applicable) Account Holder s Signature Expiration DIFFERENT BILLING ADDRESS Have home billing sent to a different address If your mailing address is different than your permanent address, please complete the following: Last First MI Address City State Zip Code Please Note: If paying by Check, Debit Card or Credit Card, then a $20 month convenience fee applies. Initial premium will not be billed, and must be paid at the time of application. Regardless of payment option, initial premium payments are not subject to the convenience fee. CHM_IFP2014_APP P a g e 3

4 H. TERMS, CONDITIONS AND AUTHORIZATIONS I, as the undersigned applicant or guardian, hereby apply to the carrier(s) offering the coverage indicated on this Application. I acknowledge that by applying for these products, coverage is provided by Coordinated Health Mutual, d/b/a InHealth Mutual. I understand, acknowledge and agree to the following: 1. By signing below, I represent and warrant as follows: (a) I have thoroughly read and understand this Health Application and the questions asked herein; (b) I have answered each and every question set forth in this Application; (c) all of the answers to each of the questions are accurate, complete and true; and (d) I did not sign a blank or partially completed Application. I agree that InHealth, in their sole discretion, may rescind my policy on the basis of any material misrepresentation or fraudulent response to any question in this Application. I further agree that if a policy is issued, it will be issued by InHealth in full reliance and in consideration of the information, answers and statements contained herein. 2. No issuance, waiver, modification or change of policy or any of InHealth s rules or amendments shall be binding upon InHealth unless it is in writing and signed by an authorized officer of InHealth. 3. I am responsible for reporting any changes in the number of my eligible dependents or any change in my residence or other contact information. 4. Following the final review and acceptance of the application, an identification card will be issued as evidence of coverage, along with additional information relating to health care coverage. 5. I understand that InHealth Mutual will rely on the information provided in this application as the basis for establishing premium rates for health care coverage. I acknowledge that I may be required to provide additional information or to sign an additional authorization form, if necessary. 6. I agree that benefits payable on my account, or my dependent s account under this health care benefit plan will be paid directly to the provider(s) of care. 7. Premium payments are due on the first day of each month. This is called the Premium Due, and all premiums must be paid on or before the Premium due date. If premium payments are not received within 10 days of the Premium Due, InHealth reserves the right to assess a late fee of $ I understand that I have the right to cancel this coverage within 10 days of receipt of my certificate of coverage with a full refund of any premium paid. 8. If I am applying for coverage for my domestic partner, I represent and warrant that I and my domestic partner: (a) We are in a domestic partnership of mutual support, caring and commitment; (b) We are each other s sole domestic partner and intend to remain so indefinitely; (c) Neither of us is legally married and we are not related by blood; (d) We are both at least eighteen (18) years of age and are legally competent to contract; (e) We currently reside together and have resided together in a common household for at least six (6) consecutive months and intend to reside together indefinitely; and (f) Within the past 12 months, neither of us has been involved in a different domestic partnership. 9. No agent or broker has the authority to: 1) Bind InHealth by making promises regarding eligibility, benefits or the issuance of a policy; 2) waive any answer or any portion of any answer to any question on this Application or any information InHealth requests; 3) approve coverage; 4) make or alter any contract on behalf in InHealth; or 5) waive or alter any of InHealth s other rights or requirements. All contract terms must be in writing and signed or accepted in writing by an authorized representative of InHealth to be binding on InHealth. 10. I understand that InHealth may collect personal information about me from outside sources, and that both personal and privileged information may only be disclosed to outside parties without my authorization if such disclosure is permitted by both the HIPAA Privacy Regulations (45 CFR. Parts 160 & 164) and the Ohio Revised Code I also understand that under the HIPAA Privacy Regulations and Ohio law, l have a right to see and correct personal information that InHealth collects about me, and that I may receive a more detailed description of my rights under these laws by writing to InHealth. I am signing this Application on my own behalf and on behalf of all listed dependents. An unaltered copy of this authorization is as valid as the original. I understand that I should not cancel any current health insurance coverage until I receive an approval letter and certificate of coverage/policy from InHealth. CHM_IFP2014_APP P a g e 4

5 Applicant or Guardian s Signature: : Spouse Signature: : (Dependents over 18 years of age must also sign below) Dependent Signature: : Dependent Signature: : I. AGENT/BROKER INFORMATION AND CERTIFICATION I certify, to the best of my knowledge and belief, the responses in this Application are accurate. Agency TIN Agency NPN Agency Agent/Broker (Please Print) NPN # Agent/Broker Signature Agent/Broker (Please Print) NPN# Agent/Broker Signature J. INHEALTH SALES REPRESENTATIVE/ACCOUNT EXECUTIVE Sales Representative or Account Executive (First & Last ) Region WARNING: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE OR SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. CHM_IFP2014_APP P a g e 5