Network Health Plan Application Agreement

Confidentiality Statement

In completing this application, I authorize any health care provider to release any of my medical information, including those records pertaining to the testing and treatment of mental health, alcohol and/or substance abuse, and HIV infection, to Network Health Plan medical and claims management personnel, when reasonably related to my coverage through Network Health Plan. (By signing this authorization as the Employee or Spouse, you also authorize the release of medical information for any covered minor dependents and/or any covered dependents for which you have legal guardianship.)

I also authorize any health care provider to release any and all of my medical records to Network Health Plan when reasonably related to coverage for quality measurement or administrative purposes. This authorization is valid while my coverage is in effect or for as long as a claim is pending, whichever is longer. I understand I am entitled to inspect and obtain a copy of the released records and that I may revoke these authorizations at any time except to the extent that a health-care provider has already acted in reliance upon them. I also understand that I am (or my authorized representative is) entitled to receive a copy of this complete form. By signing this form, I authorize Network Health Plan to release this information for a period not to exceed 30 months from the date this application is signed.

If any law or provider requires an additional authorization for the release of medical records, I will be required to sign a special consent for the release of this information. I understand that Network Health Plan will make every effort to protect my privacy at all times.

I understand that failure to authorize the release of medical information to Network Health Plan may cause significant delays in the processing of my claims. I also understand that Network Health Plan the right to release claim information received from health care providers to Network Health Plan contracted entities to accomplish its obligations under the contract.

All information furnished by me on this application is true and complete to the best of my knowledge.