Arise Health Plan Application Agreement

Terms and Conditions

I hereby enroll for coverage under the insurance coverage(s) for which I am presently eligible, or for which I may become eligible. I understand and agree that the information obtained by using this Application will be used by Insurer or Third Party Administrator (“TPA”) to determine eligibility for benefits. I, on behalf of myself, my spouse and my dependent child(ren), if any, named herein, agree to cooperate in providing Insurer or TPA with information needed to process this Application.

I acknowledge that I have read and completed the entire Application. If I received assistance in reading or completing this Application, I have identified in the space provided below the person(s) who provided me with such assistance. I additionally agree that Insurer or TPA is not liable for any statement, representation, or other information provided to me, my spouse or my dependent child(ren) that is not expressly contained in a written document provided by Insurer or TPA and signed by an authorized officer of the Insurer or TPA. I agree that no insurance will be effective until the date specified by the company on the policy after this application has been accepted. I also understand that if I decline any coverage, future changes in coverage are NOT automatic and may be subject to Insurer or TPA’s approval.

I acknowledge that:

-This application becomes part of my Medical Coverage Agreement

-The signatures shown below allow me, my spouse, or my agent (Section 9) to release to Insurer information about any person listed on my Individual and Family plan application documents.

-Under the Health Insurance Portability and Accountability Act (HIPAA), Insurer, without my authorization, may only release limited information about my selection of a plan to my spouse, adult/minor children, producer, or anyone else.

-Insurer may collect, use, or disclose the nonpublic personal information of persons listed on this application as required or permitted by law and to conduct routine business functions such as determining eligibility for enrollment, reviewing prior coverage for waiting periods, paying claims, and, if appropriate, coordinating benefits, and fulfilling other legal obligations specified in my Insurer Medical Coverage Agreement

-I have read and agree to the Terms and Conditions (Section 10) included with this application.

-I authorize Insurer to disclose information about the selection of a plan to the Agent of Record (Section 9) for the duration of coverage and final reconciliation of the Insurer account. A signed Member Authorization to Disclose Health Plan Information form is required for all other disclosures to the Agent of Record.

I declare that, to the best of my knowledge, all information I have provided with this application is true and complete, and that all of the persons for whom I am requesting enrollment are eligible for coverage. I understand that if I have made intentionally false or misleading statements on behalf of myself or any family members, the Medical Coverage Agreement may be canceled retroactively to its effective date. I further understand that it is a crime to knowingly provide false, incomplete, or misleading information for the purpose of fraudulently obtaining health coverage. Penalties may include imprisonment, fines, and denial of benefits.