Fillable Health Tradition Member Enrollment Form (Page 2 of 3) in pdf

Other Health

If you, your spouse, or your eligible dependents also have other insurance plan(s), complete the questions

below so we can coordinate health benefits with your other insurance carrier(s). It is important to complete this

Insurance

information as accurately as possible. By doing so, you will prevent unnecessary paperwork from being mailed to

you after medical services have been provided.

On the date this change will take effect, will you or any family member(s) be covered by any other group medical insurance

(not replacing this plan)? ❏ Yes

❏ No

If yes, please complete this information:

Name of person with other insurance/plan _______________________

Type of coverage:

❏ Single ❏ Family

Please list names of covered family members ____________________________________________________________

Name of insurance co. __________________________________________________

Phone No. __________________

Address ____________________________________

City ___________________

State _______

Zip __________

Group No. _________________________________

Certificate No. ________________________________________

Policy: Effective date __________ Termination date _____________ Will you be terminating coverage? ❏ Yes

❏ No

Is this a group policy/plan offered through an employer? ❏ Yes ❏ No If no, what is it offered through? _____________

Have you or any of your dependents had coverage under any other health insurance within the past 30 days?

Termination

❏ Yes

❏ No

Of Coverage

Attestation

If so, with what company and what kind of policy? Company _________________________________________________

Please complete

Kind of policy _____________________________________________________________________________________

this section if you

checked the “Lost

What are your dates of coverage under the other policy (mm/dd/yy)? Start ____/ ____ / ____ End ____/ ____ / ____

other qualifying

(If you are still covered under this plan, leave “END” blank.)

coverage” box at

the beginning of

Name of current insurance company: ___________________________________________________________________

this form.

Name of individuals covered: _________________________________________________________________________

Your identification and group number with current insurance company: ________________________________________

Reason for termination: _____________________________________________________________________________

I hereby attest that my previous health insurance coverage was terminated on ____/ ____ / ____ . I understand that

inaccuracies in reporting this date could constitute fraud or misrepresentation and could result in rescission of my health

insurance plan with Health Tradition and potential other legal consequences.

Signature Required

Signature _______________________________________________________________________ Date _____________

Printed Name ____________________________________________

AUTHORIZATION: I authorize any physician, medical practitioner, hospital, clinic, medically related facility, insurance or

Signature

reinsuring company, or third party administrator having medical information about myself or my minor children to disclose

such information to Health Tradition Health Plan, its third-party administrator, other insurers/plans (including Centers for

Medicare & Medicaid Services) and other healthcare providers as necessary for the provision or evaluation of services,

the determination of claims or requests for services or benefits under my enrollment, or the administration of the plan.

This authorization shall be valid for two and one-half years from the date shown below. I agree that a photographic copy

of this authorization shall be valid as the original. I or my authorized representative can request and receive a copy of this

authorization from the Plan at any time I am enrolled with this Plan. I or my authorized representative have the right to

revoke this authorization in writing at any time.

Signature Required

__________________________________________

Employee Signature

Date Signed

Spouse Signature (if to be insured)

Date Signed

__________________________________________

Adult Dependent Signature

Date Signed

Adult Dependent Signature

Date Signed

ACKNOWLEDGEMENT: I understand that Health Tradition Health Plan reserves the right to accept or decline this

application in whole or in part. I further understand that no contractual right is created by this application or advance

premium payment and the same shall not be considered accepted unless or until the benefit plan is issued to me.

If a benefit plan is issued, I understand and agree with all notices, including, but not limited to, premium billings and

Explanation of Benefits required to be sent under the terms of the benefit plan will be sent to the Subscriber. I have read

this application in its entirety and certify the information is accurate and complete. I understand and agree that any false

statements or omissions may void any benefit plans issued based on this application. I further understand a person who

submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

❏ I hereby apply for the group coverage and authorize deductions from my earnings for the amount required, if any, to

cover any contribution for group coverage.

Signature Required

__________________________________________

Employee Signature

Date Signed

Spouse Signature (if to be insured)

Date Signed

Health Tradition Member Enrollment Form Page 2

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