Group Coverage Application Form (Page 4 of 4) in pdf

PLEASE READ AND SIGN BELOW

I hereby apply for the Policy coverage specified below. I understand that this application is subject to your acceptance and to the conditions and exclu-

sions contained in the agreement. I agree to pay charges for these coverages as billed. I am covered by Medicare Part A and Part B.

I acknowledge and agree that any personally identifiable health information about me (“Protected Health Information”) is protected by The Health

Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, and that, in accordance with those laws, Independence Blue Cross

and/or Highmark may use and disclose Protected Health Information for payment, treatment and health care operations as described in its Notice of

Privacy Practices. I understand that a copy of Independence Blue Cross and/or Highmark’s Notice of Privacy Practices is available at

I understand that the Independence Blue Cross/Highmark Blue Shield MedigapSecurity policy that I am applying for has a preexisting condition

provision. Under this provision, benefits related to any preexisting condition will not be provided for six months after I enroll in MedigapSecurity.

I also understand, however, that the preexisting condition provision will not apply to these benefits if, when I enroll in MedigapSecurity, I have

already satisfied a preexisting condition provision for the benefits under another Medicare supplement policy or the preexisting condition provi-

sion is waived because I am an “eligible person” as defined by federal and Pennsylvania laws and regulations.

If I was previously enrolled under another Blue Cross

and Blue Shield

policy or a Medicare supplement policy with another company with a preexisting

condition limitation, coverage under this policy for a preexisting condition limitation will only be excluded to the extent of the time that I did not satisfy

the preexisting condition exclusion period under the previous policy and in no event shall such preexisting condition exclusion exceed six (6) consecutive

months from the effective date of my coverage under this policy.

“Preexisting Condition” means a disease or physical condition for which medical advice or treatment has been received by me within one

hundred eighty (180) days immediately prior to my initial effective date under this agreement or any endorsement made part of this policy.

I understand that I can find complete details of the program(s) in the Policy which I will receive after I return this Application Form.

I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the State where the indi-

vidual resides) on this application means that I have read and understand the contents of this application. If signed by an authorized individual, this

signature certifies that: 1) this person is authorized under State law to complete this application and 2) documentation of this authority is available

upon request by Independence Blue Cross and Highmark Blue Shield or by Medicare.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim

containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a

fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Benefits underwritten or administered by Independence Blue Cross and Highmark Blue Shield — independent licensees of the Blue Cross and Blue

Shield Association.

FOR OFFICE USE ONLY

Your Signature: ______________________________________________________

IDENT. No.

REAS

■ ■

■ ■ ■ ■

Today’s Date:

ORIG

EFF

TO BE COMPLETED BY GROUP ADMINISTRATOR

EFF

Is enrollee full-time employee?

Yes

No How many active employees are in your group? _________________________

■

Employer: _______________________________________________ Group # ________________________________

Employer’s Address: ________________________________ Phone #: _______________________________________

If you are the authorized representative, you must provide the following information:

Name: ____________________________________________

Address: _____________________________________________________________________________________

■ ■ ■

■ ■ ■ ■

Phone Number:

Relationship to Applicant: __________________________

1901 Market Street, Philadelphia PA 19103-1480

Not connected with or endorsed by the U.S. Government or the federal Medicare program.

Independence Blue Cross and Highmark Blue Shield

are independent licensees of the

Blue Cross and Blue Shield Association.

Group Coverage Application Form Page 4

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