Healthcare Dental and Vision Application

Healthcare Dental and Vision Application

Employer/Group Name:

Patient Information

Date of Birth:    Gender: Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Subscriber Date of Birth:    Relationship to Subscriber:

Coverage Selection

Coverage Requested: Dental Vision

Employee Only Employee + Spouse Employee + Child(ren) Family

Dependent Information (if applicable)

DOB:    Relationship:

DOB:    Relationship:

Medical / Dental / Vision History

Consent, Authorization and Certifications

By signing below I authorize the release of medical, dental and vision information necessary to process enrollment, eligibility verification and claims. This authorization includes disclosure of treatment dates, billing records, and diagnostic information to the plan administrator, insurer and their agents for the purposes stated above.

I certify that the information provided on this application is true and complete to the best of my knowledge. I understand that omission or misrepresentation of facts may result in denial of benefits, rescission of coverage, or recovery of payments. I authorize payment of benefits directly to participating providers where applicable and consent to assignment of benefits for covered dental and vision services.

I acknowledge my right to revoke this authorization in writing, except to the extent that action has already been taken in reliance on it. This authorization will expire on the authorization expiration date provided below or one year from the date signed, whichever occurs first, unless a different expiration is specified.

I understand that I am financially responsible for any non-covered services, copayments, deductibles, or amounts not paid by the insurer. I consent to the release of protected health information for treatment, payment, and health care operations as necessary to administer this coverage.

I acknowledge receipt of the privacy practices notice and understand that my protected health information will be used and disclosed as necessary for enrollment and claims. I further authorize the insurer and its agents to obtain records from any providers or facilities to verify coverage or process claims.

HIPAA / Privacy Acknowledgment: I acknowledge that I have received or been offered a copy of the privacy practices notice and consent to the uses and disclosures described therein.

Additional Authorizations

Coordination of Benefits / Third Party Liability: I agree to cooperate with the plan and its agents in coordination of benefits activities and to provide information necessary to determine other coverage or third-party liability.

Fraud and Misrepresentation: I understand that intentional misrepresentation of material facts may result in criminal or civil penalties, and/or termination of coverage.

If signing on behalf of the patient, state relationship and authority to sign:

Sign Now