Fillable Form (Nf) Az-72000 - Humana Employee Enrollment Form

Form (Nf) Az-72000 - Humana Employee Enrollment Form - 2008 Page 3

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Last name:

First name:

Agreement

AZ-72000-AA

3/2008

My dependents and I understand and agree:

•

The information obtained by use of this authorization may be used by Humana to make claims determinations, determine eligibility for coverage, eligibility for

benefits under an existing policy and plan administration.

•

Any information obtained will not be released by Humana to any person or organization except to reinsuring companies, the Medical Information Bureau, Inc. or

other persons or organizations performing health care operations or business or legal services in connection with an application, claim or as may be otherwise

lawfully required, or as I (we) may further authorize. Once personal and health (including medical, dental and pharmacy) information is disclosed pursuant to this

authorization, the recipient may redisclose it and the information may not be protected by federal and state privacy requirements.

•

A photographic copy of this authorization shall be as valid as the original.

•

This authorization shall be valid for two years from the date shown below and I have the right to revoke this authorization at any time by writing to Humana’s

Privacy Office.

This document, together with any supplements, will form part of any contract and be the basis for any certificate of coverage/certificate of insurance issued.

Signature

- please sign below if enrolling or waiving group coverage.

AZ-72000-SA

3/2008

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: _______________________________________________________________________

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(NF) AZ-72000 3/2008