Group Health Cooperative of South Central Wisconsin Application Agreement

PLEASE COMPLETE THIS APPLICATION

This application is a legal document. It is important that you fill it out completely and correctly in order for you and your family to receive proper and timely coverage. An incomplete application will delay the application process and your access to clinical appointments and services. If you submit your application and payment by mail, please make sure the Individual Plan Application is filled out completely and signed.

Do not cancel your current health coverage. The enrollment process generally takes one to two weeks. We will promptly notify you regarding your acceptance or rejection into the GHC-SCW Individual Plan. Coverage is effective on the first of the month following receipt of the application if the application is received by the 15th of the month. If received on or after the 16th of the month it will be effective the first of the month following the next month. (Example if the application is received on December 20th, it would be effective on February 1st.) All plans renew with rate adjustments on January 1st of the following year of the effective date of policy. Payment Method Please submit your payment for the first month’s coverage along with your application. You may pay with a personal check or money order. GHC-SCW will not accept payment with a business check. If you would like to preauthorize your monthly payments, please complete form A attached. GHC-SCW will still require a check for the first month’s coverage. Failure to pay your Individual Plan premium by the due date could result in termination of coverage. To receive information about covered services or for questions regarding the Individual Plan application process, call the GHC-SCW Sales Department at (608) 828-4831

SIGNATURE

My signature on this form represents my agreement to the following Terms and Conditions: (1) The information I have provided is true and correct to the best of my knowledge; (2) I have the proper legal authority to provide this information and understand that I may be required to submit proof of this authority. My signature represents the signature of each dependent in accordance with permission he/she and/or the proper legal authority has previously permitted; (3) My plan benefits have been fully explained to me; (4) Information will be used and disclosed in accordance with state and federal laws and regulations for the sole purpose of treatment, payment or health care operations and adherence to other legal documents as applicable. Such laws and regulations may pertain to a dependent’s individual right to privacy which may supersede those provided to me as subscriber, including consideration given to extended family members (e.g. step or non-biological children) or 12-17 year old minors; (5) On behalf of myself and my subscriber’s, I hereby consent to the provision of care and treatment by GHC-SCW and its employees.

By signature below, I (we) authorize Group Health Cooperative of South Central Wisconsin (GHC-SCW) to instruct my financial institution to deduct my premium payments from the account designated above. I authorize the financial institute to debit the amount of my premium from my designate account. This authorization is to remain in full force and in effect until GHC-SCW and depository have received written notification from me (us) of its termination within 30 days of termination date.