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Carrier Agreements

Health First Commercial Plan,Inc Application Agreement

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

Please read the following carefully before completing your application. This notice describes how medical information about you may be used and disclosed.

Health First Health Plans is committed to protecting the privacy of your medical and member information also known as Protected Health Information (PHI). We collect and maintain this information to administer our business, to provide you with products, services, information of importance, and to comply with certain legal requirements. This notice tells you about the ways in which we may use and disclose your information. It also describes your rights and certain obligations we have regarding the use and disclosure of your information.

We are required by law to protect the privacy of your information, notify affected individuals following a compromise of unsecured PHI, provide this notice about our privacy practices, and follow the privacy practices that are described in this notice.

We may use and disclose PHI without your authorization for the following reasons. Not every use or disclosure will be listed below. However, all the ways we’re permitted to use and disclose information will fall within one of the categories.

To provide treatment: We may disclose your PHI to your health care providers (doctors, dentists, pharmacies, hospitals and other caregivers) who may request it in connection with your treatment. We may also disclose your PHI to health care providers (including their employees and business associates) in connection with preventative health, early detection and disease and case management programs.

For payment purposes: We may use or disclose your PHI to administer your health care policy or contract which may involve: determining your eligibility for benefits, paying claims for services you receive, making medical necessity determinations, coordinating your care of other services and coordinating your coverage with other plans.

For healthcare operations: We may use and/or disclose your PHI to support daily business activities for healthcare operations, which may include activities like quality management, care management, care coordination, credentialing, medical review, auditing, legal services, business planning and development, public health activities, abuse or neglect, legal proceedings, law enforcement officials, worker’s compensation and as required by law.

We may disclose your PHI to a representative acting on your behalf. You must appoint your representative in writing and provide the written appointment to Health First Health Plans at the address included below. We may disclose your PHI to a friend or family member who is involved in, or helps pay for your care. In addition, we may disclose your PHI to an entity assisting in disaster relief efforts so that your family can be notified about your condition, status and location. You have the right to object to disclosure of your PHI to a friend or family member in this case.

Other than the uses and disclosures described above, we will not disclose your PHI without your written authorization. Health Plan requires your written authorization for most uses and disclosures of psychotherapy notes (psychotherapy notes are notes made by a mental health professional during a private, group or family therapy session and kept separate from the medical record) for marketing (other than a face-to-face communication between you and a Health Plan workforce member or a promotional gift of nominal value) in which financial payment is received or before selling your protected health information resulting in financial or non-financial payment. Additionally, other uses and disclosures of medical information not covered by this notice or by the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission in writing at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

You have rights related to the use and disclosure of your PHI. To exercise these rights, you may contact the locations below:

Health First Health Plans

6450 US Highway 1 Rockledge, FL 32955

PH: 1.855.443.4735

ACKNOWLEDGEMENT and AGREEMENT: I understand and agree to abide by all terms, conditions and provisions of the Contract. I have read and understand this Application including the conditions of enrollment. I understand if this Application is accepted it will become part of the Contract. My signature (either signed below or electronically submitted) indicates my acceptance of these terms and that the information entered in this Application is complete, true and correct.

ACKNOWLEDGEMENT

IT IS IMPORTANT YOU REVIEW AND UNDERSTAND THE FOLLOWING BEFORE YOU SIGN. By submitting an application for benefits, I agree with all of the statements listed below:

  • I attest the information submitted in this Application is true and accurate to the best of my knowledge. Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

  • Once benefits are effective, they are contingent on timely and accurate payment of premiums and any other cost sharing as outlined in the policy. If payment is not accurate and paid on time, my coverage will be terminated. If terminated for non-payment, I may no longer be eligible to enroll in Health First Health Plans.