Healthcare Health Plan Document

HEALTHCARE HEALTH PLAN DOCUMENT

Member Information

Patient Name:

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

Insurance & Subscriber Information

Plan Selection & Coverage

Plan Type: HMO PPO EPO Other

Coverage Effective Date:

Coverage Level: Individual Family

Medical History (for plan and care coordination)

Benefits, Premiums, and Member Responsibility

Monthly Premium Amount:

Annual Deductible:    Out-of-Pocket Maximum:

By enrolling, the member acknowledges responsibility for premiums, copayments, coinsurance, and any charges not covered by plan terms, including services rendered by out-of-network providers when not pre-authorized. The member understands that failure to pay premiums may result in termination of coverage in accordance with plan rules.

Authorizations, Consent and Privacy

Authorization to Obtain and Release Information: The member authorizes any physician, hospital, medical facility, employer, insurer, or other entity to release medical, dental, mental health, substance abuse, and billing information as necessary to determine eligibility, process claims, coordinate care, and administer benefits under the plan. This authorization includes medical records related to diagnosis, treatment, and payment.

Assignment of Benefits: The member assigns benefits payable under the health plan to the provider when required by the provider as a condition of receiving services. The member acknowledges that assignment does not relieve the member of financial responsibility for non-covered services, co-payments, deductibles, or amounts not paid by the insurer.

HIPAA Acknowledgment: I acknowledge receipt of the plan's Privacy Notice describing uses and disclosures of protected health information for treatment, payment, and healthcare operations and my rights concerning that information.

I acknowledge I have received and reviewed the Privacy Notice.

Authorization Expiration Date:

Termination, Cancellation, and Fraud

Termination and Cancellation: Coverage terminates in accordance with plan documents for reasons that include, but are not limited to, member request, nonpayment of premiums, change in eligibility status, or material misrepresentation. The plan reserves the right to retroactively deny coverage if material eligibility information is omitted or incorrectly represented.

Fraud and Misrepresentation: The member certifies that all information provided is complete and accurate. Intentional misrepresentation, omission, or fraud in enrollment or claims may result in termination of coverage, recovery of paid benefits, civil penalties, and criminal prosecution under applicable law.

Coordination of Benefits & Subrogation

Coordination of Benefits: If the member has coverage under more than one plan, benefits will be coordinated in accordance with applicable plan provisions to avoid duplication of payment. The member agrees to provide information about other coverage upon request.

Subrogation and Recovery: The member agrees to cooperate with the plan's recovery efforts and to assign to the plan any rights to recovery against third parties to the extent of benefits paid by the plan.

Member Certification

By signing below, I certify that the information provided in this Health Plan Document is true and complete to the best of my knowledge. I acknowledge that acceptance into the plan is subject to plan terms, eligibility verification, and payment of any required premiums. I consent to the terms, authorizations, and acknowledgements contained herein.

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