MercyCare Health Plans

Terms and Conditions

Read the Terms and Conditions and Sign the Application

I acknowledge that I have read and completed the entire application. I agree that the answers are, to the best of my knowledge and ability, complete and true.

I understand that my answers are the basis for the policy that is issued. I agree that no insurance will be effective until the date specified by MercyCare on the policy.

I understand that any intentional misrepresentation relied upon by MercyCare may be used to deny a claim. I further understand that this contract can be voided if within the first 24 months from the date of the policy it is determined that I or a family member made an intentional misrepresentation in the application.

I understand that I may request copies of this application and MercyCare’s privacy practices. I agree that a photocopy is as valid as an original. A legible facsimile or electronic signature shall have the same force as the original. If my or my dependents' information has changed from what is indicated on the application prior to the effective date of coverage, I will immediately notify MercyCare about the change.

I understand that MercyCare may request additional information and documentation to confirm the information provided in this application, and that acceptance of this application may depend on my providing the requested information and documentation.