Healthcare Benefits Schemes

HEALTHCARE BENEFITS SCHEMES

Participant Information

Participant Name:

Date of Birth: Month   Day   Year

Emergency Contact

Scheme Enrollment Details

Select the benefits schemes to enroll in (check all that apply):

Primary Healthcare Plan

Dental Coverage

Vision Coverage

Mental Health Services

Chronic Care Management

Maternity Coverage

Telehealth Services

Supplemental Benefits (specify in notes)

Dependent Enrollment

List dependents to be included under Family coverage (attach additional sheet if necessary):

Relationship:   Date of Birth: Month   Day   Year

Relationship:   Date of Birth: Month   Day   Year

Insurance Coordination

I have other health insurance coverage: Yes    No

Medical History

Terms, Conditions, and Authorizations

Eligibility and Acceptance: Enrollment is subject to verification of eligibility and compliance with scheme rules. The plan administrator reserves the right to deny or modify coverage where eligibility criteria are not satisfied or where misrepresentation of material facts is discovered.

Premiums and Contributions: By enrolling I authorize required premium contributions to be deducted from my payroll or billed to me as provided in the plan documents. I understand that premiums may change and that continued coverage is contingent upon timely payment of required contributions.

Coverage Effective Date: Coverage, if approved, will begin on or after Effective Date: Month   Day   Year . Coverage prior to this date will not be provided unless expressly authorized in writing.

Claims and Benefits: Benefits are subject to the terms, conditions, exclusions, limitations and maximums set forth in the plan documentation. Approval of a claim does not guarantee payment for services that are excluded or are not medically necessary under plan rules.

Termination: Coverage may be terminated for cause, including non-payment of premiums, fraud, or loss of eligibility. Termination will be effective as specified in plan rules and applicable law.

Fraud and Misrepresentation: Intentional misrepresentation or omission of material facts in connection with enrollment or claims may render coverage void and may subject the enrollee to civil and criminal penalties.

Privacy and Release of Information: I authorize the release of medical and administrative information necessary to establish eligibility, process claims, coordinate benefits, and administer the plan. This authorization includes release to plan administrators, providers, and relevant auditors. I understand that information disclosed under this authorization may be subject to re-disclosure and may no longer be protected by privacy rules once shared with third parties for the purposes described.

Acknowledgment: I have read and understand the terms above and agree to be bound by the plan documents and administrative policies applicable to the selected schemes. I certify that the information provided on this form is complete and accurate to the best of my knowledge.

Authorization Expiration Date: This authorization to release medical information and to enroll in the selected schemes shall expire on: Month   Day   Year , unless earlier revoked in writing.

HIPAA Acknowledgment: I acknowledge receipt of the plan privacy practices and understand how my protected health information will be used and disclosed for treatment, payment, and healthcare operations related to benefits administration.

Consent to Electronic Communication: Where permitted by law, I consent to receive plan notices and communications in electronic form. I understand I may request paper copies in accordance with plan procedures.

Additional Information / Notes

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