Independent Health Application Agreement

Certification and Consent – Signature REQUIRED

I certify that the information given on this application is current, true and correct to the best of my knowledge and I have read and agree to this statement. I understand that this application and my spouse or eligible dependent’s subsequent receipt of health care services are subject to the terms of the applicable coverage document. I understand that if I enroll in a health coverage product through my employer, my employer is responsible for remitting premium payments on my behalf, or in the case of self-insured employers, my employer is responsible for paying my health care claims.

I consent to any person or institution that shall have rendered health services to me or to any member of my family under the applicable coverage document to make available any photographs, records or information regarding such services to Independent Health. Any information received or generated by Independent Health shall be kept confidential and secure as required by applicable laws, rules, regulations or contract. I also consent to Independent Health disclosing my health information or the health information of any member of my family for Independent Health’s or a provider, health plan, health care clearinghouse or other covered entity’s treatment, payment or health care operations as permitted by applicable laws, rules and regulations. This consent shall remain in effect until revoked by me in writing or a maximum of 24 months from this authorization.

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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.