Healthcare Gold Plan Renewal

HEALTHCARE GOLD PLAN RENEWAL

Member Name:    Member ID:    Plan:

Member Information

Emergency Contact

Plan Renewal Details

Current Plan Effective Date:    Renewal Term Requested:    12 months    6 months

Coverage Effective Date:

No change to coverage    Add dependents    Remove dependents    Change plan tier

Monthly    Quarterly    Annual

Bank draft (ACH)    Credit card    Check

I authorize automatic renewal and premium collection as indicated above. I understand that enrollment in automatic renewal does not change my right to cancel coverage under the policy terms and that this authorization will remain in effect until revoked in writing.

Dependent Information (if applicable)

Dependent 1

Dependent 2

Dependent 3

Medical Information

Authorization, Acknowledgment and Consent

I certify that the information provided on this renewal form is true and complete to the best of my knowledge. I understand that any material misrepresentation or omission of facts may result in rescission of coverage, denial of claims or retroactive cancellation in accordance with plan provisions and applicable law.

I authorize Healthcare Gold Plan and its designees to obtain, use and disclose medical and enrollment information necessary to process this renewal, determine eligibility, and administer benefits. This authorization includes release of records from providers, hospitals, pharmacies and other insurers for underwriting, claims adjudication, and quality assurance purposes.

I understand that coverage is subject to plan terms including premium payment, timely submission of documentation, and applicable waiting periods. I agree to notify the insurer promptly of any change in address, dependents, or other information affecting eligibility. Failure to make timely premium payments may result in termination of coverage retroactive to the last paid date.

By checking the box below I acknowledge receipt of the plan's Notice of Privacy Practices and authorize use and disclosure of protected health information as stated above.

I acknowledge receipt of the Notice of Privacy Practices and consent to use/disclosure of my health information as described.

Certification

By signing below I certify under penalty of perjury that I am the person named on this form or an authorized representative with the legal authority to complete this renewal. I authorize the insurer to process this renewal request and to charge any authorized payment method for required premiums. I understand I may rescind this renewal in writing in accordance with the plan's cancellation provisions.

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