Form Sb.ee.07.az - Employee Enrollment Form

G. Signature

I authorize United HealthCare Insurance Company and its affiliates ("UnitedHealthcare and Affiliates") 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 the purpose

of the disclosure and use of my information is to allow UnitedHealthcare and Affiliates to make decisions regarding eligibility, enrollment, 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

UnitedHealthcare and Affiliates representative in writing, except to the extent that action has already been taken in reliance on this authorization. As

required by HIPAA, UnitedHealthcare 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. 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 for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be

deducted from earnings. I (we) have not given the agent or any other persons any health information not included on the application. I (we)

understand that UnitedHealthcare and Affiliates 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. I (we) know that I (we) or the applicant’s authorized representative have

the right to ask to receive a copy of this form. I have a continuing obligation to report changes in health status (e.g. received medical advice,

diagnosis, care or treatment) after I sign the enrollment form and before receipt of my identification card. 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