Regence BlueCross BlueShield of Oregon - WA (Clark County) Application Agreement

Signatures

You, your spouse/domestic partner, and children age 18 and older (if applicable) must sign this application. All signatures apply to “Certification of Completion and Correctness” and “Authorization for Use and Disclosure of Protected Health Information.

Certification of Completion and Correctness

The answers I provided in this application for enrollment are complete and correct.

• I understand that Regence relies on these answers when making coverage and rating decisions.

• It is a crime to knowingly provide false, incomplete or misleading information for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of benefits.

• If coverage is terminated due to fraud or intentionally misleading statements, Regence will reimburse my premiums minus any amount paid for my claims; if the amount Regence has paid in claims is greater than the premiums I paid, I will have to reimburse Regence for the difference.

• I will inform Regence in writing if anything happens before my effective date that makes this application incomplete or incorrect.

• I do not have coverage until Regence approves my application and assigns an effective date.

• Regence may contact me to clarify information in this application.

• I understand that I have the right to inspect the information in my file.

• I understand that if I answered “No” to being a tobacco user and my answer changes to “Yes” any time after submitting this application, I must notify Regence. A surcharge will be applied.*

Authorization for Use and Disclosure of Protected Health Information

I understand that Regence may request or disclose health information about me or my covered dependents for the purpose of facilitating health care, payments or benefit administration, or as required by law.

This health information may be related to treatment or services performed by:

A doctor, dentist, pharmacist or other physical or behavioral health care practitioner

• A clinic, hospital, long-term care or other medical facility

• Any other institution providing care, treatment, consultation, pharmaceuticals or supplies

• Another insurance carrier or health plan

Health information may include, but is not limited to: claims records, correspondence, medical records, billing statements, diagnostic imaging reports, lab reports, dental records, or hospital records (including nursing records and progress notes). This authorization may not be used for psychotherapy notes; such notes will require a separate authorization.