Health Alliance Medical Plans Application Agreement

Acknowledgement & Signature Signature – Adult applicants must sign this form below. Parent or guardian signature is required for applicants under the age of 18. By signing this form, you certify the following:

• I have read this document or it has been read to me. • The answers provided within this entire application for coverage are, to the best of my knowledge, true and complete. • Neither Health Alliance nor the agent has the authority to waive a complete answer to any question, determine coverage or insurability, alter any contract, or waive any of the insurance carrier’s other rights and requirements.

• I understand that if I intentionally omit or provide false information on or in relation to this application, this policy may be canceled retroactively, in which case any claim I submit may not be paid by Health Alliance.

I understand that the information I have provided in this application will be used by Health Alliance and its affiliates to make decisions regarding eligibility and enrollment.

I understand that the information provided also includes my spouse/civil union spouse and/or dependents’ information.

I understand that I may be asked for authorization to disclose my medical, claim or benefit records at a later time.

I understand that I should retain a duplicate copy of this application for my own records.

I understand that no coverage shall be in force until approved by Health Alliance. If approved, coverage will be in force as of the effective date determined by Health Alliance.

I understand that this application will become part of the contract between Health Alliance and me.

I understand that protected health information described in this form may be used by, or disclosed to or by, organizations and persons who are not subject to federal or state privacy laws.

I understand I may revoke this authorization at any time by giving advance written notice to Health Alliance. Revocation of this authorization form will not affect actions Health Alliance took in reliance on this form prior to the written notice of revocation.

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

I authorize the insurance carrier to electronically transmit the information contained herein.

I agree this Authorization shall be valid for two and one-half (2 ½) years from the latest signature date below.

If this application was taken over the phone or on the computer, I acknowledge that I, myself, have not actually signed this application but instead hereby authorize the insurance carrier to print “Electronically Acknowledged” on the signature line of the application, and I agree that such printing shall be treated as a valid signature for all purposes of this form. I acknowledge that the insurance carrier has verified my identity for this purpose in accordance with any applicable law or regulation.

By signing below, I acknowledge that I have read and understand this document and I am signing of my own free will.