Enrollment Application/change/cancellation Request Form - Unitedhealthcare (Page 4 of 4) in pdf

IMPORTANT INFORMATION

In order to make choices about your health care coverage and treatment, we believe that it is important for you to understand how your

plan operates and how it may affect you. In an ever-changing environment, the information can never be complete and we urge you to

contact us if, after enrollment, your Certificate of Coverage or other materials do not answer your questions. Further information is available

at or at the toll-free Customer Care number located on the back of your identification card or on other plan materials.

1. We do not provide health care services or make treatment decisions. We help finance and/or administer the health benefit plan in which

you are enrolled. That means:

• We make decisions about whether the health benefit plan you chose will reimburse you for care that you may receive.

• We do not decide what care you need or will receive. You and your provider make those decisions.

2. We may enter into arrangements where another entity carries out some of our duties, but those entities must operate consistently with

our commitment to your plan.

3. We may use individually identifiable information about you to identify for you (and you alone) procedures, products, and services that

you may find valuable.

4. We contract with networks of physicians and other providers. Our credentialing process confirms public information about the

providers’ licenses and other credentials, but does not assure the quality of the services provided.

5. Physicians and other providers in our networks are independent contractors and are not our employees or agents. We do not control

nor do we have a right to control your provider’s treatment or plan.

6. We may enter into agreements with your physician or other provider to share in the cost savings that our approach may generate. We

encourage providers in our network to disclose the nature of those arrangements with you. If they do not, we encourage you to talk to

your provider about these arrangements.

7. We encourage physicians and other providers to talk with you about care you or your provider think might be valuable.

8. We will use individually identifiable information about you as permitted by law, including in our operations and in our research. We will

use anonymous data for commercial purposes including research.

Statement of affirmation and authorization to obtain and disclose information in connection with eligibility for coverage.

I (we) request the indicated group coverage for myself and, if the plan provides, for my dependents. I authorize any required premium

contributions to be deducted from earnings.

I (we) authorize all providers of health services or supplies and any of their representatives to give the following to the insurance

company(ies): any available information about the health history, condition, or treatment of any persons named in this request. I (we)

authorize the insurance company(ies) to use this information to determine eligibility for health coverage and eligibility for benefits under an

existing policy.

I (we) also authorize the insurance company(ies) to give this information to its (their) representatives or to any other organization for the

reason notified above. I (we) agree that this authorization is valid for 30 months from the date below. I (we) know that I (we) have the right

to ask for and to receive a copy of this authorization.

I understand that the Certificate of Coverage and other documents, notices, and communications regarding my health benefit plan may be

transmitted electronically.

I (we) have not given the agent or any other persons any health information not included on the Request for Coverage. I (we) understand

that the insurance company(ies) 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 Request for Coverage and any attachments.

LG.EE.12.OR 9/12

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Enrollment Application/change/cancellation Request Form - Unitedhealthcare Page 4