For on-exchange policies, please visit your carrier's website:
For off-exchange policies, please view your carrier's application agreement below:
Sharp Health Plan Application Agreement
Disclosures and Signatures
Please read the following carefully. Each applying family member age 18 and older is required to review the completed application and provide their own signature on the following page. Keep a copy of this application for your records.
Access Dental Disclosures
I understand that if I have indicated that coverage under the Plan is to be provided only for the dependent child on this form, I am responsible for payment of the required Premium and compliance with all of the provisions and conditions of the Disclosure Form / Contract.
California law prohibits an HIV test from being required or used by health insurance companies as a condition of obtaining health insurance coverage. Access Dental Plan will not require that an HIV test be required as a condition of obtaining coverage. In accordance with California Health and Safety Code section 120980, Access Dental Plan complies in all respects with the prohibition against the unauthorized disclosures of an HIV test.
RIGHT OF REIMBURSEMENT: I, on my behalf of my Dependent(s) listed on this Enrollment Application, hereby agree that in the event any dental services provided to me or my Dependent(s) covered by Access Dental Plan are the primary financial responsibility of another party because of other dental coverage, I will fully inform Access Dental Plan and will execute such assignments, liens or other documents which may be necessary to enable Access Dental Plan to recover the value of services and supplies provided.
NOTICE: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison. In accordance with the disclosure requirements of California Health & Safety Code, Section 1363 (h), this is to advise you that Access Dental Plan’s ratio of health care expenses to premiums received for the last fiscal year with respect to Access Dental Plan’s Individual & Family Plans was 62.0%.
Sharp Health Plan Disclosures
I alone am responsible for the accuracy and completeness of the information provided on this application. I have personally reviewed all information provided on this application, even if I did not fill out the application myself. To the best of my knowledge and belief, all information on this application is accurate, true and complete. If Sharp Health Plan determines that there is fraud (by act, practice or omission) or an intentional misrepresentation of material fact in the information on this application, I understand that coverage may be rescinded as allowed by law.
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison.
In accordance with the disclosure requirements of California Health & Safety Code, Section 1363 (h), this is to advise you that Sharp Health Plans’ ratio of health care expenses to premiums received for the last fiscal year with respect to the Sharp Health Plan Individual & Family Plans was 84.3%.
I understand that I may be subject to an audit by Sharp Health Plan, at which time I will need to provide proof of residency, date of birth and dependent eligibility (if applicable). I further understand that I must provide Sharp Health Plan with any new information that arises after the submission of this application but before my enrollment with Sharp Health Plan begins.
I understand that this plan will only cover services provided through my plan’s network of providers and facilities, unless I receive prior written authorization from Sharp Health Plan, or unless the services are emergency care services or out-of-area urgent care.
If I indicated that I have a language preference other than English and have completed the English version of this application (or version other than in my language preference), I confirm that I understand the questions on this application.
I understand that California law prohibits an HIV test from being required or used by health care plans as a condition of obtaining coverage.
Depending on income level and family size, I understand that I may be eligible for financial assistance to help pay for health coverage if I purchase my coverage through Covered California. Sharp Health Plan benefit plans are available through Covered California. I must apply during an open or special enrollment period. Open enrollment is from November 1st through December 15th. Special enrollment periods for all individuals enrolling through Covered California are from October 15th through October 31st and from December 16th through January 15th. An application submitted during these two special enrollment periods will be treated the same as an application submitted during the open enrollment period. However, I understand that in order for coverage to begin on January 1st, I must submit my application on or before December 15th of the preceding calendar year. If I have a life change such as marriage, divorce, a new child or loss of a job, I can apply at the time the life change occurs (“special enrollment period”).
I understand that I have the right to use Sharp Health Plan’s internal dispute resolution process if any dispute or controversy arises regarding the performance, interpretation, or breach of the agreement between myself (and/or enrolled dependent) and Sharp Health Plan, whether in contract, tort, or otherwise. If I am unsatisfied with the result of the dispute resolution process, I understand that I have the right to voluntary binding arbitration, which is the final step for resolving complaints. Upon receipt of a demand for arbitration, Sharp Health Plan agrees to utilize a neutral arbiter from an appropriate entity. Arbitration will be conducted in accordance with the rules and regulations of the chosen entity.