Oscar Virginia Application Agreement
Please Read the Following Terms & Conditions Carefully
On behalf of myself and any covered dependents, to the extent permitted by law, I hereby authorize all health care providers who have rendered service to any of us and any payers of claims to provide to Oscar any records pertaining to care provided, claims paid, and our medical history for purposes of medical management and utilization review, claim payment, continuity of care, care management, and any purpose required by law. I authorize Oscar to provide to any network provider or out-of-network provider who has a need to know the following: records pertaining to care provided, claims paid. and our medical history for purposes of medical management and utilization review, claim payment, continuity of care, care management, and any purpose required by law. This authorization lasts for the term of coverage of the policy. You and any person authorized to act on Your behalf, and any authorized representative, are entitled to receive a copy of this form. 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, may be subject to rescission of coverage, denial of coverage, or termination of coverage. I am applying for coverage for myself, my spouse and my eligible dependent children named on this application. All statements made within this form are true and accurate to the best of my knowledge.
By typing your name, you are signing this Agreement electronically and consenting to its terms & conditions. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. Note that Oscar will use either your triggering event date or date the application was submitted to Oscar to determine your effective date of coverage. We will not use the signature date on this application.