Highmark Blue Cross Blue Shield West Virginia

For off-exchange policies, please view your carrier's state-specific application agreement:

NOTIFICATION AND AUTHORIZATION

My/our signature on this Application indicates that I/we have read and fully understand the following statements:

I/we hereby apply for health care plan coverage for myself and/or my eligible dependents listed on this Application. I/we understand and agree that the terms and conditions of our coverage will be controlled by the written Agreement with Highmark West Virginia and that they may adopt reasonable policies, procedures, rules and interpretations, consistent with the language of that Agreement, to administer the program. I/we recognize that our coverage will only apply to admissions that occur and services that are provided on or after the effective date of our coverage.

I acknowledge and agree that any personally identifiable health information about me or my enrolled dependents (“Protected Health Information”) is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other privacy laws, and that, in accordance with those laws, Highmark West Virginia may use and disclose Protected Health Information for payment, treatment and health care operations.

A copy of Highmark West Virginia’s Notice of Privacy Practices is available on the Highmark West Virginia Web site or from the Highmark West Virginia Privacy Office.

I/we understand that the Agreement is available to all residents of West Virginia, and that this Application is subject to the provisions of the Agreement.

I/we understand that the receipt of the benefits under this program is subject to Highmark West Virginia’s determination of medical necessity and appropriateness. Except for emergencies or delivery-related admissions, all inpatient admissions are subject to review by Highmark West Virginia prior to the proposed admission.

I can confirm that everyone applying for health insurance on this Application is a U.S. citizen, national or other individual lawfully present in the United States.

I can confirm that no one applying for health insurance on this Application is incarcerated (detained or jailed).

I know that I must tell Highmark Blue Cross Blue Shield West Virginia if any information I supplied on this Application changes. I can call 1-888-809-9121 to report any changes.

EFFECTIVE DATE OF COVERAGE

I/we understand/agree that, subject to the conditions of enrollment on this Application, coverage will be effective for individuals listed on this Application following receipt of a completed Application and payment of the first premium in full:

a) on the first day of the following month if the Application and premium payment are received between the first and 15th of the month

-OR-

b) on the first day of the second month if Application and premium payment are received between the 16th and the last day of the month

To the best of my/our knowledge and belief, the information provided on this Application is true and correct.

I also understand that any attempts to qualify for the program chosen through fraud or other intentional misrepresentation of a material fact will result in termination of such contract.

If typing your name in the signature field: I/We understand and I/We am/are creating an “Electronic Signature” that carries the same legal obligation as a written signature and I/We am/are agreeing to all of the terms and conditions set forth within this application.

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.