Paramount Health Care Application Agreement

AGREEMENT:

ON BEHALF OF MYSELF AND LISTED DEPENDENTS, I UNDERSTAND THAT MY ENROLLMENT AND BENEFITS ARE IN ACCORDANCE WITH THOSE DESCRIBED IN THE PARAMOUNT GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT. I UNDERSTAND THAT I CAN OBTAIN A COPY OF THIS AGREEMENT FROM PARAMOUNT OR MY EMPLOYER. I AGREE TO CHOOSE A PARTICIPATING PARAMOUNT PHYSICIAN FOR PRIMARY CARE. I AGREE TO MAKE DIRECTLY TO THE PROVIDERS OF HEALTH CARE SUCH CO-PAYMENTS AS ARE PROVIDED FOR IN THE MEMBER HANDBOOK. PARAMOUNT IS A COVERED ENTITY UNDER HIPAA, AND IS PERMITTED TO USE, OBTAIN AND DISCLOSE MEMBER PROTECTED HEALTH INFORMATION (PHI) TO PERFORM PARAMOUNT OPERATIONS IN ACCORDANCE WITH PARAMOUNT’S NOTICE OF PRIVACY PRACTICES. I UNDERSTAND I CAN OBTAIN A COPY OF THIS NOTICE FROM PARAMOUNT UPON REQUEST. I SHALL COOPERATE AND ASSIST PARAMOUNT IN THE EXERCISE OF ITS SUBROGATION AND COORDINATION OF BENEFITS RIGHTS INCLUDING AS AGAINST MY OWN OTHER PAYORS AND AS SET FORTH IN MY EMPLOYER’S GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT. I AGREE TO SUBMIT ANY DISPUTES WITH PARAMOUNT THROUGH THE GRIEVANCE PROCEDURE SET FORTH IN THE PARAMOUNT GROUP MEDICAL AND HOSPITAL SERVICE AGREEMENT. IF APPROPRIATE, I AUTHORIZE MY EMPLOYER TO DEDUCT FROM MY WAGES THE AMOUNT REQUIRED (IF ANY) TO COVER MY CONTRIBUTION FOR COVERAGE. ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST HEALTH PLAN, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD. IF, AFTER SIGNING THIS APPLICATION, YOU DECIDE TO CANCEL THIS AGREEMENT, YOU MAY DO SO BY SENDING A CERTIFIED LETTER WITHIN SEVENTY-TWO (72) HOURS TO PARAMOUNT AT THE ABOVE ADDRESS. I CERTIFY THAT ALL THE ABOVE INFORMATION IS CORRECT.