Fillable Enrollment/change Form - Schnectady Office (Page 2 of 2) in pdf

Enrollment/change Form - Schnectady Office Page 2

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AUTHORIZATION

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information,

or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and, in New York, shall also be subject to civil

penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

On behalf of myself and any listed dependents, I (we) hereby apply for membership in MVP. I understand that benefits provided under MVP’s Healthy NY plan may be subject to preexisting

condition limitations. If applicable, a medical questionnaire will be forwarded to you for your completion. A preexisting condition is a condition (whether physical or mental), regardless of the cause

of the condition, for which medical advice, diagnosis, care or treatment was recommended or received within the sixmonth (6) period ending on the enrollment date. We will exclude coverage for

health care services during the first twelve (12) months of this Contract that relate to preexisting conditions.

We will credit to the Covered Person the time he was covered under previous health insurance plans, if the previous coverage was continuous to a date not more than sixtythree (63) days prior

to the Enrollment Date of this Contract.

Additionally, no preexisting condition exclusion will be imposed on an “eligible individual” as defined in section 2741(b) of the federal Public Health Service Act, 42 USC §300gg41(b).

I authorize my employer to deduct from my earnings the necessary contribution, if any, required of me.

I hereby authorize any licensed physician, hospital or other health care provider to furnish MVP with such medical information about myself and my minor eligible dependents listed on the

application that may be required to allow MVP to administer my benefits. This authorization excludes the release of any information about previously administered tests for HIV antibodies,

Tcell counts, AIDS or ARC.

I hereby certify that the statements made are true and complete to the best of my knowledge and belief.