Security Health Plan of Wisconsin,Inc. Application Agreement

Read and sign this application

• I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.

• I know that I must tell Security Health Plan if anything changes from what I wrote on this application. I can visit www.securityhealth.org or call 1.855.862.6859 to report any changes. I understand that a change in my information could affect the eligibility for member(s) of my household.

• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting hhs.gov/ocr/office/file.

• I know that my information on this form will only be used to determine eligibility for health coverage and will be kept private as required by law.

• Note the name of anyone who is seeking health care coverage through this application who is incarcerated (detained or jailed)

• I understand that my information will be used to check eligibility for health coverage. If the information doesn’t match, I may be asked to send proof to Security Health Plan.

The person who filled out Section A should sign this application. If you’re an authorized representative, you may sign here.