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For off-exchange policies, please view your carrier's application agreement below:
Alliant Health Plans Application Agreement
Terms, Conditions and Authorizations
Please read this section carefully before signing the application.
I understand that although Alliant Health Plans requires payment with my Application, sending my initial premium with this Application, and the receipt of my payment by Alliant Health Plans, does not mean that coverage has been approved. I am applying for the coverage selected on this Application. I understand that, to the extent permitted by law, Alliant Health Plans reserves the right to accept or decline this Application, and that no right whatsoever is created by this Application. I understand that if my Application is denied, any premium paid will be refunded.
Eligible Dependents include the subscriber’s spouse and all children until attaining age 26. Children include natural children, legally adopted children and stepchildren. Also included are your children (or children of your spouse) for whom you have legal responsibility resulting from a valid court decree. Foster children whom you expect to raise to adulthood and who live with you in a regular parent-child relationship are considered children. However, for the purposes of this contract, a parent-child relationship does not exist between you and a foster child if one of both of the child’s natural parents also live with you. In addition, Alliant does not consider a welfare placement of a foster as a dependent, as long as the welfare agency provides all or part of the child’s support.
Incapacitated Dependent: A dependent in which the Applicant or the Applicant’s spouse is the court-appointed legal guardian; and the dependent is mentally or physically incapable of earning a living as determined by the Georgia Department of Human Resources, and the dependent is chiefly dependent upon the Applicant for support and maintenance, provided that the onset of such incapacity occurred before the dependent was 26.
I am responsible to timely notify Alliant Health Plans of any change that would make me or any dependent ineligible for coverage.
I understand Alliant Health Plans may convert my payment by check to an electronic Automated Clearinghouse (ACH) debit transaction and that my original check will be destroyed. The debit transaction will appear on my bank statement although my check will not be presented to my financial institution or returned to me. This ACH debit transaction will not enroll me in any Alliant Health Plans automatic debit process and will only occur each time I send a check to Alliant Health Plans. I understand that Alliant Health Plans may, at its discretion, attempt to process the payment again within 30 days, and agree to an additional $35 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I understand that all checking transactions will remain secure, and my payment by check constitutes acceptance of these terms.
By signing this Application, I agree and consent to the recording and/or monitoring of any telephone conversation between Alliant Health Plans and myself or my authorized representative.
I acknowledge and agree that the cell phone number and the contact information that I have provided to Alliant may be used to contact me to pursue any debt collection or to correspond with me regarding my account. I authorize Alliant or its contractors or brokers to contact me regarding debt collection or my account by using my cell phone number or other forms of identification provided to Alliant. I hereby acknowledge that Alliant or its contractors or brokers may contact me using an auto-dialer.
I understand I am applying for individual health coverage which is not part of any employer-sponsored plan. I certify that neither I nor any dependent is receiving any form of reimbursement or compensation for this coverage from any employer. I understand that I am responsible for 100% of the premium payment and I am also responsible to ensure that premiums are paid. The 21st Century Cures Act is the only exception to this rule.
I acknowledge that I have read the Terms, Conditions, and Authorizations, and I accept such provisions as a condition of coverage. I represent that the answers given to all questions on this Application are true and accurate to the best of my knowledge and belief, and I understand they are being relied on by Alliant Health Plans in accepting this Application. Any act, practice, or omission that constitutes fraud or intentional misrepresentation of material fact found in this Application may result in denial of benefits, rescission or cancellation of my coverage(s).
I authorize and expressly consent that Alliant Health Plans and its affiliated companies may send email communications instead of sending communications by mail, including but not limited to legally required Plan Notices, enrollment, billing and explanation of benefits statements, to the email address I have provided on this Application. I understand that I can revoke this authorization or request paper copies at any time free of charge by contacting Alliant Health Plans Customer Service at (800) 811-4793.
I give this authorization for and on behalf of any Eligible Dependents and myself. I am acting as their broker and representative.
I hereby acknowledge that Alliant Health Plans has informed me of the following prior to my enrollment in their health care coverage plan:
number, mix and location of participating/network health care providers;
limitations of choices of participation/network health care providers;
disclosure of contractual relationship between participation/network provider and Alliant Health Plans;
application shall be altered solely by the Applicant or with his or her written consent.
Authorization for Use of Protected Health Information
By signing below: I authorize Alliant Health Plans, or a broker, subsidiary or affiliate that has a Business Associate Agreement with Alliant Health Plans, to obtain any medical records or other health history information concerning me and any family member listed on my Application from any physicians, hospitals, pharmacies, other health care providers, pharmacy benefits managers, health benefits plans, health insurers, medical or pharmacy benefit administrators, Consumer Reporting Agencies, MIB, Inc., formerly Medical Information Bureau (MIB), and/or insurance support organizations.
This authorization is subject to revocation at any time by written notice to Alliant Health Plans except to the extent that Alliant Health Plans has already taken action in reliance on this authorization. If I revoke this authorization after I initially apply for coverage, I understand that I/we will not be considered for coverage. If I revoke this authorization after I ask to upgrade my coverage or add a family member, I understand that the change will not be made. I understand that if my and/ or my family’s information is to be received by individuals or organizations that are not health care providers, health care clearinghouses or health plans governed by federal privacy regulations, my/our information might be re-disclosed by any of those recipients and will not be protected by federal privacy regulations. A copy of this authorization is available to me, or to my authorized representative, upon request and will serve as the original.
Authorization for use of Protected Health Information (PHI) is valid for the initial term of the policy, automatically renewing as the policy renews, unless written revocation is provided by the policy holder. Failure to renew the policy will result in revocation of authorization, effective 24 months from the date of termination.
Conditional Receipt
THIS RECEIPT DOES NOT PROVIDE ANY COVERAGE UNTIL ALL THE TERMS AND CONDITIONS LISTED BELOW ARE MET.
Alliant Health Plans has received from the named Applicant an advance deposit equal to the first month’s premium together with an application for designated health insurance coverage. Such payment is accepted subject to the following conditions:
Subject to the provisions of the contract, the coverage applied for will be effective from, and the contract date as of, the day following acceptance by Alliant Health Plans, unless otherwise specifically stated, provided that the payment evidenced by this receipt is the full first month’s premium and provided that Alliant Health Plans determines that as of the date of the Application all proposed covered persons were acceptable for coverage and for the benefits applied for. If the Application is not approved by Alliant Health Plans said Plan shall incur no liability and the payment evidenced by this receipt will be refunded to the Applicant. No one has the authority to waive or modify any of the terms or conditions of this receipt.
If you do not receive a contract within 60 days, please contact Alliant Health Plans Customer Service at (800) 811- 4793.
Abbreviated Notice of Insurance Information Practices
PRIVACY ACT. Georgia state law establishes standards for the collection, use and disclosure of information gathered in connection with insurance transactions. The Application attached to this notice contains specific personal questions about you and your dependents. We need your answers to decide if you qualify for coverage. We are required to advise you that personal information may be collected from persons other than you or other individuals proposed for coverage. An investigative consumer report may be made to help us obtain additional medical data from physicians or hospitals.
ALL DATA CONFIDENTIAL. Official Code of Georgia, Code Section 33-39-5, subsection (c) (1 through 4) requires that:
Personal information may be collected from persons other than the individual or individuals proposed for coverage;
Such information as well as other personal or privileged information subsequently collected by the insurance institution or broker may in certain circumstances be disclosed to third parties without authorization;
A right of access and correction exists with respect to all personal information collected; and,
The notice prescribed in subsection (b) of the above referenced Code Section will be furnished to the Applicant or policyholder upon request.
ACCESS TO YOUR DATA. You have the right to see or obtain a photocopy of your personal information which we have. You also have the right to send us a written request if you want any of your personal information to be amended, corrected or deleted. If you wish to have a more detailed explanation of our information practices, please contact Alliant Health Plans Customer Service at (800) 811-4793.
Payment Methods
I (we) hereby authorize Alliant Health Plans to present debit entries from the bank account referenced above and the depository named above to debit the same from such account. I (we) understand that I am (we are) responsible for the validity of the information on this form. If Alliant Health Plans erroneously deposits funds into my (our) account, I (we) authorize Alliant Health Plans to initiate the necessary debit entries, not to exceed the total of the original amount credited. I (we) understand that because this is an electronic transaction, these funds may be withdrawn from my account as soon as the above noted periodic transaction dates. In the case of a transaction being rejected for Non-Sufficient Funds (NSF), I (we) understand that Alliant Health Plans may at its discretion attempt to process the payment again within 30 days, and agree to an additional $35 charge for each attempt returned NSF which will be initiated as a separate transaction from the authorized recurring payment. I (we) understand that Alliant Health Plans will cancel an Auto Pay enrollment that fails for two consecutive months.
I (we) agree to comply with all certification requirements of Alliant Health Plans and the applicable program regulations, rules, handbooks, bulletins, standards, and guidelines published by Alliant Health Plans or its authorized affiliate(s) or subcontractor(s). I (we) understand that any falsification or concealment of a material fact may be prosecuted under federal and state laws.
I (we) will continue to maintain the confidentiality of records and other information relating to clients covered by programs offered through Alliant Health Plans in accordance with applicable state and federal laws, rules and regulations.