Healthcare Health Insurance Renewal Form

Healthcare Health Insurance Renewal Form

Patient Information

Patient Name:

Date of Birth:    Gender:

Current Insurance Information

Renewal and Coverage Details

Current Policy Effective Date:   Requested Renewal Effective Date:

Select coverage tier (select one):

Individual    Individual + Spouse    Family

Dependents to be Covered

Dependent 1 Name:  DOB:

Dependent 2 Name:  DOB:

Dependent 3 Name:  DOB:

Premium Payment Authorization

Preferred payment method (select one):

Bank draft (auto-debit)    Credit/Debit card    Check    Employer-paid/COBRA

Medical History (for underwriting)

Authorization, Certification and Privacy Acknowledgment

By signing below, I certify under penalty of law that the information provided on this form is true, complete and accurate to the best of my knowledge. I authorize the insurer, its agents and representatives to verify any information provided and to obtain medical records and billing information necessary to evaluate and process this renewal application, including but not limited to records from physicians, hospitals, and other healthcare providers.

I authorize the release of protected health information to the insurer and its designees for purposes of underwriting, claims administration, and premium collection. This authorization is limited to information relevant to the review of this renewal application. I understand that I may revoke this authorization in writing, except to the extent that action has already been taken in reliance on it.

Assignment of Benefits: If coverage includes assignment, I authorize payment of benefits directly to the provider where applicable and understand that I remain financially responsible for any non-covered services. I further agree to notify the insurer promptly of any material change in the information provided on this form prior to the requested renewal effective date.

This authorization shall expire on: . If left blank, authorization will remain valid for purposes of this renewal application until the renewal effective date or until revoked in writing.

I acknowledge receipt of and have read the insurer's privacy practices and understand my rights regarding protected health information. I have the right to request restrictions on certain uses and disclosures and to revoke this authorization as provided above.

Certification of Changes and Acknowledgment

I understand that acceptance of this renewal application and issuance of coverage is subject to review and underwriting approval by the insurer. Submission of this form does not guarantee renewal. Any misrepresentation or omission of material facts may result in denial of coverage or rescission of the policy.

If this form is completed by a person other than the patient, the signer certifies that they are authorized to act on behalf of the patient and must provide their relationship to the patient in the signature block below.

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