Form Sg.ee.14.ny - Employee Enrollment - 2013 Page 4

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G. Signature
I authorize UnitedHealthcare Insurance Company of New York 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.
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.
Any person who knowingly and with intent to defraud any insurance company or other person who 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 shall also be subject to a civil penalty not to exceed five
thousand dollars and the stated value of the claim for each such violation.
Date
Employee Signature for all applying
Spouse Signature (if applying for coverage)
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