HAP Application Agreement (HMO and PPO)
Agreement and signature By executing this application, all applicants understand, agree and represent all of the following without limitation:
We have read this application or it has been read to us and we understand its terms and conditions.
The answers are, to the best of our knowledge, true and complete.
In some instances, a follow-up telephone call or email may be required to verify information provided in this application.
We may be required to provide proof of eligibility (marriage, divorce, birth, adoption, loss or addition of other coverage) satisfactory to HAP as a condition of acceptance of this application and the issuance of coverage. HAP must be notified of any of these events that might change an applicant’s eligibility for coverage. Notice must be received within 30 days of the event in order to provide coverage, terminate coverage and/or adjust premiums. HAP must be notified within 30 days of any change in name, address, email address or telephone number, eligibility or entitlement to Medicare or Medicaid – or the addition or change in any source of coverage or reimbursement for services related to an accident or injury to which we may be entitled. Failure to provide timely and complete notice of changes as noted above may result in a lapse in coverage and nonpayment of services. HAP is not responsible for a lapse in coverage when notice is not provided.
We have received and reviewed any state or federal required disclosures.
We do not have the authority to waive a complete answer to any question, determine coverage or insurability, alter any contract or waive any HAP requirement.
The coverage applied for is not an employer-sponsored group health plan and it does not comply with state and federal small employer or other contract laws.
We represent that no one applying for coverage is receiving any form of reimbursement or compensation for this coverage from any employer, other than a small employer, as allowed under federal law.
We are personally responsible for the premium payment associated with this coverage. We understand and agree that HAP does not accept premium payment from third parties, except from a spouse, or when appropriate, from a parent, legal guardian, agent or other person or entity that is specifically allowed by law to pay premium on our behalf.
If we currently have medical coverage through another company, we understand the benefits provided under this coverage may be reduced in accordance with the coordination of benefits provision in the coverage documents.
If this application for coverage is accepted, coverage will be effective on the date specified by HAP. We understand that acceptance of premium and fees do not assure coverage.
If selected, we have provided authorization for automatic withdrawal from a specified bank account or credit card for premium payment and administrative fees.
Premiums already paid will be refunded if coverage is not issued.
Our answers to questions posed by this application are intentional representations of material facts and we understand that should those answers contain fraudulent or false information, coverage may be denied or subject to rescission if initially issued.
If coverage is rescinded, we understand and agree that we will be financially responsible for any medical claims expense incurred on our behalf and that HAP may offset any premiums to be returned to us by an amount not to exceed incurred claims expense.
Each applicant waives his or her right to receive a hard copy of their coverage documents and this application, but understands that he or she will be given a right to specifically request a hard copy of such documents if accepted for coverage. The applicants further waive any right they may have to claim that HAP may not raise issues concerning the accuracy of the statement contained in this application if he or she is not given a hard copy of this application.
We understand and agree that required legal notices and communication (including coverage documents, renewal notifications and other documents concerning coverage or rights under the contract or policy) may be delivered electronically to the email address designated and not through U.S. mail. We understand that we have the right to paper copies of any and all documents concerning this coverage at no cost and that this consent to electronic communication may be canceled at any time without charge. Cancellation of this consent can be exercised and requests for paper copies can be sent to: Customer Service at 2850 W. Grand Blvd., Detroit, MI 48202. Updates to the email address can be sent to Customer Service. In order to obtain electronic documents from HAP’s website, we recommend the use of commercially available web browsers. HAP’s website contains documents in PDF format that may require Adobe Reader or other commercially available software to access.
Any applicants that do not meet the definition of spouse will be split into two contracts or policies. Dependents will remain with the primary applicant unless otherwise directed.
We attest that if not purchasing pediatric dental benefits from Delta Dental (through HAP), we will purchase (or have purchased) benefits from a certified, stand-alone dental carrier. HAP will rely upon my attestation in order to be reasonably assured that pediatric dental coverage will be purchased. Without this assurance, medical coverage will not be provided.
We can confirm that no one applying for medical coverage on this application is incarcerated, detained or jailed.
We understand that any person currently eligible for or enrolled in Medicare or any person currently incarcerated will not be covered under this contract/policy.
We understand that if accepted, the primary applicant will be set up as the subscriber. In the future, should the subscriber request to terminate their coverage, the spouse and/or dependent(s) can request to retain coverage under the existing contract or policy. HAP must be notified of this request at the time the subscriber’s coverage is cancelled. We also understand that all agreements, signatures, and obligations agreed to in this application are binding and transfer to the subscriber listed on the adjusted contract or policy.
If coverage is issued, we understand and agree that the subscriber has the authority to cancel coverage and make coverage changes under the contract/policy with regards to adult dependents. HAP will notify adult dependents of any changes made.
If coverage is issued, we understand and agree that any adult dependent covered under the contract/policy has the authority to cancel their own coverage. HAP will notify the subscriber of any changes made by an adult dependent.
If coverage is issued, we understand and agree that the licensed agent of record on the contract/policy can request the following changes on behalf of the individuals named in this application if these changes are requested in writing or via email.
a. Change the plan selected on this application to another plan offered by HAP. b. Cancel coverage under the plan selected on this application for one or more of the individuals covered under the contract/policy. c. Add or remove adult and/or pediatric dental coverage for all individuals covered under the contract/policy. HAP will notify the subscriber and all applicable adult dependents covered under the contract/policy of the requested changes.
This document, together with any supplements or amendments, will form part of and be the basis for any coverage issued. In order for your paper application to be processed, the HAP Personal Alliance team will enter the fully completed and signed paper application into our system. We will electronically sign the application and if applicable process payment on your behalf, but the paper application containing your signature will be the controlling legal document. By signing below, you consent to this process. You may revoke your consent at any time through written notice delivered through U.S. mail, fax or email to HAP, Attention: HAP Customer Service, 2850 W. Grand Blvd, Detroit, MI 48202.
Authorization Those applicants accepted for coverage authorize any physician, medical or health care practitioner, hospital, clinic, veterans administration facility, other medical or medically related facility, third-party administrator, pharmacy, pharmacy benefit manager, pharmacy related facility, insurance, HMO or reinsuring company, the Medical Information Bureau, Inc., agent, employer or a consumer reporting agency having information regarding myself and my dependents, including information concerning, advice, diagnosis, treatment and care of the physical, psychiatric, mental or emotional conditions, drug, substance or alcohol abuse, illness and copies of all hospital or medical records, prescription drug records, nonpublic personal health information and any other nonmedical information to share any and all such information with HAP, its reinsurer, its legal representatives and its affiliates.
This authorization will not be used by HAP to conduct a medical underwriting function for the purpose of establishing eligibility or premiums associated with the coverage being applied for.
HAP, or its reinsurers, may release information in its file to other companies to whom you may apply for life or health coverage, or to whom a claim for benefits may be submitted. We understand and agree to the following:
The information obtained by use of this authorization may be used by HAP to determine eligibility for coverage, eligibility for benefits under existing coverage, plan administration and to make claim determinations.
If the decision is made not to sign this authorization, HAP will decline to enroll us in a medical plan or to give us medical benefits.
Any information obtained will not be released by HAP to any person or organization except reinsuring companies, the Medical Information Bureau, Inc. or other persons or organizations performing health care operations or business or legal services in connection with any application, claim or as may be otherwise lawfully required, or as we may further authorize.
Once personal and health information (including medical, dental and pharmacy) information is disclosed pursuant to this authorization it may be re-disclosed by the recipient and the information may not be protected by federal and state privacy requirements.
A copy of this authorization is available to us or our legal representative upon written request.
A photographic copy of this authorization shall be as valid as the original.
This authorization shall be valid until revoked.
We have the right to revoke this authorization at any time.
To revoke this authorization, we must do so in writing and send written revocation to HAP Customer Service, 2850 W. Grand Blvd, Detroit, MI 48202 or email to Yourhap@hap.org.
The revocation will not apply to information that has already been released in response to this authorization.
The revocation may adversely affect our application, a claim or a pending action.
The revocation will become effective after it is received by HAP Customer Service.
Disclosure
HAP and its subsidiaries do not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation or health status in the administration of the plan, including enrollment and benefit determinations.
Please, sign, date and mail to: HAP 26877 Northwestern Hwy, Suite 420 Southfield, MI 48033-9903 Attention: HAP Personal Alliance Or scan the completed application and email to hap@personalalliance.org