Fillable Employee Enrollment Form (Page 4 of 4) in pdf

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Required Disclosure Notice for PPO & HMO Consumer Choice Benefit Plans for groups with 2-99 employees

Below is the Required Disclosure Notice for Group PPO & HMO Consumer Choice Benefit Plans Issued in Texas. To obtain a copy of the required

Consumer Choice Disclosure Notice for Consumer Choice POS Benefit Plans Issued in Texas, please consult your insurance agent.

If your employer has selected the Consumer Choice PPO Benefits Health Plan, Consumer Choice HMO Benefits Health Plan or the Consumer

Choice POS Benefits Health Plan, your plan in whole or in part does not provide state-mandated health benefits normally required in Texas health

benefit plans.

A consumer choice standard health benefit plan may provide more affordable health benefits for you although, at the same time, it may provide

you with fewer health benefits than those normally included as state-mandated health benefits in Texas health benefit plans. Please consult with

your Benefit Administrator to discuss the state-mandated health benefits that are reduced and/or excluded.

Excluded PPO State Mandates

Excluded HMO State Mandates

Chemical & Alcohol Dependency

TMJ

Oral Contraceptive Drugs & Devices

Home Health Care

TMJ

Serious Mental Illness

Invitro

Speech & Hearing

The Consumer Choice Health Benefit Plan may include requirements and/or restrictions on deductibles, coinsurance, copayments, or annual or

lifetime maximum benefit amounts that differ from other PPO & HMO plans. I understand that I may obtain from the Department of Insurance

a consumer brochure with more information on Consumer Choice Health Benefit Plans, either by visiting the TDI website at

consumer/index.html, or by calling 1-800-252-3439.

By signing this application, I acknowledge that I was offered the opportunity to apply for an accident and sickness insurance policy or evidence of

coverage in the same category that most closely approximates the consumer choice health benefit plan offered.

TX-72000-NOTICE 5/2008

Signature

- please sign below if enrolling or waiving group coverage.

If you decide not to sign this authorization, Humana cannot complete your plan enrollment or determine your premium rate due to the

inability to obtain the necessary information.

Employee or legal representative signature: _____________________________________________

Date: ____________________

Name and relationship of legal representative: _______________________________________________________________________

TX-72000-SA 5/2008

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TX-72000 5/2008

Reorder# TX-51340-SB 11/2008

Employee Enrollment Form Page 4