Fillable Form Sg.ee.14.az - Employee Enrollment

G. Signature

I authorize UnitedHealthcare and affiliates to obtain, use and disclose my medical, claim or benefit records, including any individually

identifiable health information contained in these records. The term “UnitedHealthcare and affiliates” includes the following depending upon

the coverage selected: Medical Coverage provided by UnitedHealthcare of Arizona, Inc. (HMO), UnitedHealthcare Insurance Company

(PPO/Insurance), or All Savers Insurance Company (PPO/Insurance). Dental Coverage provided by UnitedHealthcare Insurance Company.

Vision Coverage provided by UnitedHealthcare Insurance Company. Life, Short-Term Disability (STD), Long-Term Disability (LTD) Insurance

provided by UnitedHealthcare Insurance Company. 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 30 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.

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.14.az - Employee Enrollment - 2013 Page 4