Form Sb.ee.10.fl - Employee Enrollment Form

Declining coverage due to existence of other coverage:

F. Waiver of Coverage

I understand that by waiving coverage at this time, I will

Spouse’s Employer’s Plan

Individual Plan

not be allowed to participate unless I qualify at a special

I decline all coverage for:

Covered by Medicare

Medicaid

enrollment period or as a late enrollee, if applicable, or at

Myself

COBRA from Prior Employer

VA Eligibility

Spouse

the next open enrollment period. I also understand that

Tri-Care

Dependent Children

pre-existing limitations may apply as explained in the

I (we) have no other coverage at this time

Myself and all dependents

Rights and Responsibilities brochure which I have

Other ____________________________________

received with this form.

Date

Employee Signature if waiving coverage

G. Signature

I authorize UnitedHealthcare Insurance Company and its affiliates ("UnitedHealthcare and Affiliates") to obtain,

use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. I

understand these records may contain information created by other persons or entities (including health care providers) as well as information

regarding the use of drug, alcohol, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health

services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility,

health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to UnitedHealthcare

and Affiliates. I understand the purpose of the disclosure and use of my information is to allow UnitedHealthcare and Affiliates to make

decisions regarding underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the

authorization. My refusal may, however, affect my ability to enroll in the health plan or receive benefits, if permitted by law. I understand I may

revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates representative in writing, except to the extent that action

has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare and Affiliates also request that I acknowledge

the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re-disclosed and no longer

protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed.

I understand that I am completing a joint life and health application and that each response must be complete and accurate. I (we) request the

indicated group medical coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to

be deducted from earnings. I (we) have not given the agent or any other persons any health information not included on the application. I (we)

understand that UnitedHealthcare and Affiliates 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 application and any attachments. I have a continuing obligation to report changes in health

status (e.g. received medical advice, diagnosis, care or treatment) after I sign the enrollment form and before receipt of my identification card.

UnitedHealthcare is only seeking to collect information about the current health status of those persons listed on the application. You should

not include any genetic information. Please do not include any family medical history information or any information related to genetic

services or genetic diseases for which you believe you or your dependents may be at risk.

Please maintain a copy of this authorization for your records.

Any person who knowingly and with intent to injure, defraud or deceive any insurer, files a statement of claim or an application containing any

false, incomplete or misleading information is guilty of a felony of the third degree.

Date

Employee Signature for all applying

Spouse Signature (if applying for coverage)

H. Census Information (optional)

NOTE: Responding to this question is optional and is not required. Data collected in this section will be used only to help communicate with

enrollees and inform them of specific programs to enhance their well-being. This information will not be used in the eligibility process.

1. Race, check all that apply:

White

Black, African-American

American Indian/Alaska Native

Asian

Native Hawaiian/Pacific Islander

Other Race, please specify_______________________

2. Are you of Hispanic or Latino origin?

Yes

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Form Sb.ee.10.fl - Employee Enrollment Form - 2010 Page 3

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