Florida Health Care Plans Addendum To Group Application Form (Page 2 of 2) in pdf

Florida Health Care Plans Addendum To Group Application Form Page 2

FLORIDA HEALTH CARE PLANS

ADDENDUM TO GROUP APPLICATION

IF YOU ANSWERED "YES" TO ANY OF THE QUESTIONS ABOVE (EXCEPT LAST QUESTION), YOU MUST COMPLETE THE

FOLLOWING SECTION TO THE BEST OF YOUR KNOWLEDGE AND BELIEF.

Section II. Please provide us with FULL DETAILS for each "Yes" answer to any condition(s) checked in Section I. In addition, please give

details below of last doctor visit and/or physical examination for ALL family members listed regardless of the date or reason.

Question

Name of Individual

Condition/Diagnosis

Date of

Date

Medication

Dosage

Still Taking

Date

Onset

Treatment

Prescribed

Medication

Ended

Yes

If you are providing additional sheets, check here and insert the sheets before sealing this Enrollment form. _______

I understand the purpose of the disclosure and use of my information is to allow FHCP and Affiliates to make

decisions regarding underwriting and premium risk rating. I understand this authorization is voluntary and I may

refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health plan or receive

benefits, if permitted by law. I understand I may revoke this authorization at any time by notifying my FHCP and

Affiliates representative in writing, except to the extent that action has already been taken in reliance on this

authorization. As required by HIPAA, FHCP and Affiliates also request 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.

I represent that all information supplied in this form is true and complete. I have read and agree to the Conditions

of Enrollment and Misrepresentation on this Florida Small Group Business (2 - 50 Eligible Employees) Employee

Enrollment/Change Form.

Misrepresentation: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a

statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony

of the third degree.

Employee Name (Print)____________________________________

Group Name:_______________________________

X_____________________________________

______________

Date:_

Employee Signature

MED UW EE 11/07

Florida Health Care Plans Addendum To Group Application Form Page 2