Enrollment/change Form (Page 3 of 3) in pdf

*Applicant Name: ________________________________________ (required)

☐

Dependent's Last Name

Reason for Medicare Eligibility

Subscriber or

Dependent

☐

Over 65

Effective Date Of:

Dependent's First Name

☐

Disabled

Part A

☐

Kidney Disease (ESRD)

☐

ALS (Lou Gehrig's Disease)

Part B

Medicare #

Part D

WAIVER

My employer has given me an opportunity to apply for group health coverage for myself and my dependents (if applicable)

☐

I have declined to apply for coverage for

myself,

spouse,

dependents

Reason for decline: ☐ Other group health insurance ☐ Spousal Coverage ☐ Tricare/Medicare/Medicaid ☐ Individual Coverage

☐ Other reason (please explain)

_____________________________________________________________________________________________________________________

I understand that if I decide to apply for health coverage for myself and any applicable dependents at a later date, neither my dependents nor I will

be eligible for coverage until (1) my employer’s next open enrollment period, or (2) there is a qualifying event as defined in the EOC/COI.

____________________________________________________________________________

___________________________________

Employee Signature (only if you are waiving coverage)

Date:

CONDITIONS OF ENROLLMENT

Please read the following carefully.

I hereby apply for membership or request a change in membership in this Coventry Health Care of the Carolinas, Inc./Coventry Health and Life

Insurance Company (CHC Carolinas/CHL) Plan. I understand that my enrollment and benefits are in accordance with those described in the applicable

Evidence/Certificate of Coverage or Certificate of Insurance, and Group Contract or Group Policy. I authorize 1) all health providers and insurers to

furnish CHC Carolinas/CHL, and 2) all health providers and CHC Carolinas/CHL to furnish all insurers and health providers records concerning me

or any member of my family for whom information is requested for any purpose required for the coverage of benefits including, but not limited to, the

coordination of payments with other insurers or in connection with the provision of medical care. I understand that I or my authorized representative

is entitled to receive a copy of this form containing this authorization for disclosure of information. A photographic copy of this authorization shall be

valid as the original. I authorize my employer to deduct from my wages the amount required (if any) to cover my contribution for coverage. I represent

that all the above information is correct. For claim adjudication purposes, this authorization is valid for the duration of my coverage for health benefits

through CHC Carolinas/CHL. For purposes of collecting information for an insurance policy application,policy reinstatement, or a request for change

in policy benefits, this authorization shall remain valid for thirty months from the date the authorization is signed. It is further understood that CHC

Carolinas/CHL reserves the right to re-rate coverage if any supplied information is materially inaccurate or incomplete, or rescind coverage in the

event of fraud or intentional material misrepresentation.

AGREEMENT AND AUTHORIZATION

By signing this form, I agree on behalf of myself and those family members enrolled in this CHC Carolinas/CHL Plan (Dependents) for whom I have

authority to enroll and to consent on their behalf (collectively my Dependents and I shall be referred to as Enrolled Family) that CHC Carolinas/CHL

may use or disclose to third parties the information contained on this enrollment form and individually identifiable health information relating to my

Enrolled Family for purposes of administering my health insurance benefit including treatment, payment, or health care operations, as those terms

are explained in detail in CHC Carolinas/CHL’s Notice of Privacy Practices and to the extent permitted by law. My Enrolled Family’s consent includes

agreement for the use or disclosure of health information that may include diagnosis, prognosis, treatment, and payment information related to

physical and/or mental illness, including substance abuse, Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC), or Human

Immunodeficiency Virus (HIV). By signing this form, I also agree on behalf of myself and my Dependents that, to the extent permitted by law, health

care providers, insurers, claims administrators, employers, and others may disclose my Enrolled Family’s personal information including individually

identifiable health information that may include diagnosis, prognosis, treatment, and payment information related to physical and/or mental illness

including substance abuse, AIDS, ARC, or HIV to CHC Carolinas/CHL for CHC Carolinas/CHL’s administration of health insurance benefits including

treatment, payment, or health care operations purposes and other purposes permitted by law.

I HAVE READ AND AGREE TO THE STATEMENTS ABOVE. (SIGNATURE REQUIRED BELOW)

_________________________________________________________________________

___________________________________________

Applicant Signature

Date

_________________________________________________________________________

Applicant Printed Name

NC ENROLL 2016

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Enrollment/change Form Page 3

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