Member Change Form (Page 2 of 2) in pdf

IV. Applicant’s Authorization and Representation -

Read this section carefully, sign and date the application.

I hereby apply for coverage on the basis of the statements and answers to the questions herein. I hereby represent all answers to be true to the best of my knowledge and to

accurately represent the health of those persons applying for coverage and waiving coverage. I understand that these statements, answers and subsequent information I

provide are the basis for my coverage. I understand that if my application for new or additional coverage is accepted, that applicable coverage will not be

effective until after I am notified of the Effective Date.

I hereby authorize Common Ground Healthcare Cooperative (CGHC) to obtain from providers of services and hospitals, including those providers with whom CGHC

contracts for service, the medical records, including those which relate to mental health and chemical dependency treatment, relating to me and my family members to

the extent that those records are necessary for the administration of the CGHC contract, including for purposes of claims payment, case management, fraud

investigation and quality of care review. A photocopy of this authorization shall be as valid as the original and remains in effect as long as continually insured by CGHC or

until revoked.

I UNDERSTAND THAT PROVIDING FALSE INFORMATION OR OMISSION OF RELEVANT INFORMATION TO COMMON GROUND HEALTHCARE COOPERATIVE

IN THIS APPLICATION MAY RESULT IN THE DENIAL OF CLAIMS OR CANCELLATION OR RESCISSION OF COVERAGE.

SIGNATURE OF EMPLOYEE

DATE SIGNED

IMPORTANT - PLEASE READ CAREFULLY

Information provided on this application is solely for the purpose of administering the CGHC plan(s).

To enroll in Common Ground Healthcare Cooperative Plan:

 Complete the application by hand in ink.

 Answer every question, providing complete information about yourself and family members you want to cover. If information is missing or incomplete, your

enrollment may be delayed and/or your coverage may be limited.

To submit your application:

 Please review all information for completeness and accuracy.

 Be sure to sign and date the application.

CGHC.FO.1004-2016