Fillable Form Sg.ee.16.ok - Employee Enrollment - Oklahoma

G. Signature

Your enrollment in the plan is expressly conditioned upon your acceptance of all terms and conditions contained in this enrollment application.

If you do not agree to the following terms and conditions, you may not complete your enrollment.

TERMS AND CONDITIONS

As a condition of my and/or my dependents’ participation in the plan, and in consideration for the privileges that come from participation in

the plan, I hereby agree for myself and/or for my dependents as follows:

I recognize and understand that the plan contracts with physicians and other providers that make up the plan network. I recognize that all

physicians and other providers that participate in the plan network are subject to credentialing under applicable State regulations and pursuant

to the plan’s network credentialing process. I understand that such credentialing includes a review of provider education, training and

licensure. However, by participating in the plan I hereby acknowledge and accept that the plan is not a provider of medical services, and I am

aware that obtaining or not obtaining medical care involves significant risks such as serious injury and even death. I acknowledge that the

credentialing of physicians and other providers does not in any way reduce this risk. I agree to assume all risks and responsibility for, and

hold the plan harmless from, any and all claims for damages, including personal injury or death, medical expenses, disability, lost wages, and

loss of earning capacity which may be incurred or associated with medical treatment obtained through a participating physician or other

provider. I recognize that all physicians and other providers that participate in the plan network are independent contractors and not the plan’s

employees or agents and are solely responsible for any malpractice, adverse outcomes, or any other claims arising from medical treatment

rendered to me and my dependents. I HEREBY AGREE THAT THE PLAN IS NOT RESPONSIBLE NOR LIABLE FOR ANY ADVICE, COURSE OF

TREATMENT, DIAGNOSIS OR ANY OTHER INFORMATION, SERVICES OR PRODUCTS THAT I OR MY DEPENDENTS OBTAIN THROUGH A

PARTICIPATING NETWORK PHYSICIAN OR OTHER PROVIDER.

I recognize and understand that the plan does not recommend, endorse or make any representation about the appropriateness or suitability of

any specific tests, products, procedures, treatments, services, or opinions. I recognize that the plan, plan documents, and any health and

wellness information provided by the plan, are not intended or implied to be a substitute for professional medical advice, diagnosis or

treatment. I agree to confirm any medical information obtained from or through the plan with other sources, and will review all information

regarding any medical condition or treatment with my physician. I HEREBY AGREE TO NEVER DISREGARD PROFESSIONAL MEDICAL ADVICE

OR DELAY SEEKING MEDICAL TREATMENT BECAUSE OF SOMETHING I HAVE READ OR ACCESSED THROUGH THE PLAN.

I authorize UnitedHealthcare Insurance Company and its affiliates (collectively, "UnitedHealthcare") to obtain, use and disclose my medical,

claim or benefit records, including any individually identifiable health information contained in these records. I understand these records may

contain information created by other persons or entities (including health care providers) as well as information regarding the use of drug,

alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. I authorize

any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care

clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to UnitedHealthcare and Affiliates.

I understand that the purpose of the disclosure and use of my information is to allow UnitedHealthcare to facilitate the appropriate

management of treatment, services, payment and benefits. I further understand that the information disclosed will not be used for purposes

of eligibility, enrollment, underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the

authorization. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare representative in writing, except to

the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare also requires that I

acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re-disclosed and

no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 24 months after the date it is signed.

I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the

indicated group medical coverage. I authorize any required premium contributions to be deducted from my earnings. I (we) have not given the

agent or any other persons any required information not included on the application. I (we) understand that UnitedHealthcare is not bound by

any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and

any attachments.

WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an

insurance policy containing any false, incomplete, or misleading information is guilty of a felony.

Please note that if you leave out information or make a misrepresentation on this form we may be allowed by law to take one or more of the

following actions: terminate or non-renew your coverage or change your premium retroactively to the date your policy became effective.

Please maintain a copy of this authorization for your records.

Date

Employee Signature for all applying

Spouse Signature (if applying for coverage)

H. Census Information (optional)

NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with

enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process.

1. Race, check all that apply:

White

Black, African-American

American Indian/Alaska Native

Asian

Native Hawaiian/Pacific Islander

Other Race, please specify_______________________

2. Are you of Hispanic or Latino origin?

Yes

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Form Sg.ee.16.ok - Employee Enrollment - Oklahoma - 2015 Page 4

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