Healthcare Premium Plan

HEALTHCARE PREMIUM PLAN

Client Name:    Date of Birth:

Member Information

Male   Female   Other / Prefer not to say

Emergency Contact

Insurance & Subscriber Information

Plan Selection & Effective Date

Plan Tier: Individual   Family   Premium Plus

Coverage Effective Date:

Premium & Payment Terms

Premium Amount (per billing period): $

Billing Frequency: Monthly   Quarterly   Annually

First Payment Date:

Bank Draft (ACH)   Credit/Debit Card   Paper Check

Authorization for automatic debit of premiums: I authorize recurring debits in accordance with chosen billing frequency.

Medical History

Coverage, Exclusions & Waiting Periods

The Company shall provide coverage as specified in the Plan Summary and Schedule of Benefits attached to this Premium Plan. Covered services are subject to the limitations, exclusions, copayments, coinsurance and deductible provisions set forth in the Plan Summary. Pre-existing condition provisions, if applicable, are disclosed in the Plan Summary; unless otherwise stated, pre-existing condition exclusion periods begin on the coverage effective date above.

Excluded services include, but are not limited to: cosmetic procedures, experimental treatments not authorized in writing by the Company, services rendered outside the geographic coverage area, and services provided by non-participating providers except as expressly permitted. The Company retains final adjudication authority for coverage determinations and claims processing consistent with the Plan Summary.

Consent, Authorizations & HIPAA Acknowledgment

By signing this Healthcare Premium Plan, I certify that the information provided in this Application is true, complete and correct to the best of my knowledge. I authorize the Company, its representatives and designees to obtain and disclose any medical or payment information necessary to administer benefits or process claims, including information from healthcare providers, insurance carriers and benefit administrators.

I acknowledge receipt of the Privacy Practices and I authorize the release and exchange of protected health information for treatment, payment and healthcare operations as necessary to administer this plan. This authorization is valid for the duration of coverage unless earlier revoked in writing. I understand I may revoke this authorization at any time by sending a written request to the Company's administrative office; revocation will not affect disclosures made prior to receipt of the revocation.

Authorization Expiration Date:

I acknowledge and accept the terms, limitations, and conditions of coverage set forth in this Healthcare Premium Plan and the Plan Summary.

I acknowledge receipt of the privacy notice and consent to the uses and disclosures described above for treatment, payment and health care operations.

Cancellation, Refunds & Termination

Coverage may be cancelled in accordance with the cancellation provisions set forth in the Plan Summary. Voluntary cancellation by the member requires thirty (30) days' written notice and may be subject to pro rata refund of unearned premiums less administrative fees. The Company may terminate coverage for nonpayment of premium or material misrepresentation, subject to any required notice periods. Fraudulent statements or concealment of material facts may void coverage and subject the member to recoupment of claims paid.

Certification

I certify under penalty of law that the information provided herein is accurate and complete. I understand that knowingly making a false statement or misrepresentation in order to obtain benefits is grounds for denial or rescission of coverage and may subject me to criminal and civil penalties under applicable law.

Sign Now