You are enrolling in health benefits through an (AHP) Association Health Plan (the "Plan") which is governed by US Department of Labor. For more information about AHP visit: https://www.dol.gov/general/topic/association-health-plans
This Health Plan required that you are actively working; short-term and/or long-term disability could make you ineligible for the health plan.
Please complete this enrollment information statement carefully and honestly. Only the applicant should answer these questions for all covered members under the employee coverage. Please provide detailed medical information on this form to reduce the need for a phone interview. Your answers will be strictly kept confidential, subject to applicable privacy laws and regulations.
I UNDERSTAND THAT ALL STATEMENTS AND ANSWERS MADE WILL BE VALID FOR 60 DAYS FROM THE DATE SIGNED.
AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION.
Instructions: please read this authorization form carefully before signing. Your request to enroll for coverage cannot be processed without your electronic signature. You have the right to receive a copy of this form following your signature.
Protected Health Information (PHI)
We are committed to the privacy of your PHI/Personal Information and has required all business associates and vendors to agree in writing to those same protections. Despite these efforts, we are required by law to advise you that your Information may at some point fall outside of these protections, be re-disclosed and would no longer be protected.
This authorization encompasses information that is considered to be Protected Health Information and/or Personal Information. Protected Health Information (PHI) includes individually identifiable health information that is created or received by your provider, health plan or insurer, data clearinghouse, a health authority, employer, school or university.
PHI/Personal Information relates to the past, present, or future condition of your physical or mental health, healthcare provided to you, or payment for the healthcare provided to you. PHI/Personal Information does not include summary health information or information that has been de-identified according to the standards for de-identification provided for in the Health Insurance Portability Act Privacy Rule.
By signing this form, I authorize certain entities identified below to use or disclose my protected health information. Protected health information includes, but is not limited to, hospital records, physician records, lab results, mental health records and alcohol and/or drug abuse records. Protected health information may be obtained, maintained, or transmitted in any form or medium, including written, oral, or electronic.
Purpose of the Authorization Form
By signing this form, I authorize the use and disclosure of protected health information for the purposes of: determining eligibility for enrollment or benefits under a health plan; determining eligibility, or to allow the plan's designee to conduct utilization review and quality improvement activities ("Purpose").
Entities Authorized to Use and Disclose My Protected Health Information
I hereby authorize the following entities, their reinsurers, or other organizations performing business or legal services in connection with the Purpose above and their respective legal representatives ("Entities") to receive, use, and disclose my protected health information for the Purpose listed above:
(1) the Plan; (2) the Plan's third-party administrator; and (3) medical stop-loss insurance companies that may indirectly insure any health benefits provided by the Plan. (4) the Association’s marketing representatives or brokers; (5) excess or reinsurance carriers backstopping any obligations of the Plan.
I authorize Entities to disclose my PHI between themselves and their affiliated companies, to reinsuring companies, to the plan administrator or plan sponsor.
I further authorize any licensed physician, medical practitioner, healthcare provider, hospital, clinic, or other medical or medically related facility, insurance or reinsuring company, or other organization that has any record or knowledge of me to give Entities any and all PHI about me concerning diagnosis, treatment and prognosis for any physical or mental condition, including, but not limited to, all medical and healthcare records.
I understand I have a right to inspect and copy my own PHI/Personal Information to be used or disclosed. I understand that failure to sign this Authorization will result in my application not being considered.
I understand that my Personal Representative or I have a right to receive a copy of the authorization form. A simulated, faxed or copied image of this Authorization shall be as valid as the original.
Term of Authorization I further agree this Authorization will be valid until we have completed its determination of my eligibility for coverage or for 12 months from the date signed, whichever is less.
Right to Revoke I understand I may revoke this authorization at any time by giving advance written notice to the entities listed above. Revocation of this authorization form will not affect actions Entities took in reliance on this form prior to receipt of the written notice of revocation.
I understand this Health Plan has medical as well as prescription coverage exclusions. Other drugs may have age/condition limitations. A full list of exclusions can be provided upon request.
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY ELECTRONICALLY SIGNING THIS FORM, I AUTHORIZE THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I AGREE THAT A FAXED OR COPIED IMAGE OF THIS AUTHORIZATION SHALL BE AS VALID AS THE ORIGINAL. I AGREE TO RECEIVE BENEFIT DOCUMENTS INCLUDING, BUT NOT LIMITED TO: PLAN DOCUMENTS, SUMMARY PLAN DESCRIPTIONS, SUMMARY OF BENEFITS AND COVERAGE, POLICIES, CONTRACTS, AGREEMENTS, LETTERS AND NOTICES THROUGH ELECTRONIC MEDIA USING A COMPUTER WITH INTERNET ACCESS.