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8. Because of an allowed reason I do not see on this list that happened on this date. Please contact us at (312) 726-6565.
1You must apply within 60 days before or after the qualifying life event.

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By clicking "I Agree" below, you signify that: You understand and accept the Blue Cross and Blue Shield of IllinoisOklahomaTexas (BCBS) Terms, Agreements and Privacy Statement.

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Acknowledgements and authorizations

ACKNOWLEDGMENTS
BY COMPLETING AND SIGNING THIS FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:

  • This Application is not coverage. Coverage will not begin until (1) the effective date of the policy and (2) the first month's payment is made.
  • If I use an agent or broker, they cannot accept risks or change BCBSIL policies or rules.
  • If an agent, producer or broker was helping me to purchase an individual or family health or dental plan, BCBSIL may pay the broker a commission and/or other payment. If I want more detail about any payment to the agent or broker, I should ask the agent or broker.
  • If any person knowingly submits a false claim for payment of a loss or benefit or falsely misstates an important fact on this Application, coverage may be rescinded. This includes false claims or facts about me or any of my dependents. Rescission cancels the coverage back to the first day it became effective. I will be given at least 30 days´ written notice before my coverage or that of my dependents is rescinded.
  • My monthly premium will be calculated using factors approved by the State's Department of Insurance and other applicable State and Federal laws and regulations. Rates are calculated based on age, tobacco use and geographic rating factors. These factors are also used to calculate premiums for any dependents covered on my policy.
  • Coverage will start on the plan effective date only if the first monthly payment is received in full before that date.
  • I allow any of the following people or organizations to share my health information with BCBSIL or their authorized representative:
    • Health professionals, hospitals, or clinics
    • Other health or health‐related facilities
    • Government agencies
    • Pharmacy benefit managers, clearinghouses, or retail stores
    • Any other persons or firms required by law
    –  This information may include:
    • Copies of records about advice, care or treatment that were given to me and/or my dependents
    • Information about the prescription and use of drugs or alcohol (without limitation)
    • Information about mental illness
  • BCBSIL may review and research its own records for information.
  • BCBSIL will share collected information only as needed with medical entities to help manage my care.
  • Information shared with my authorization may be re-shared by BCBSIL as allowed or required by law. If such sharing is required, the person or agency getting the information will be responsible for protecting it.
  • This authorization is valid for two years from today, or until I cancel coverage.
    –  I have the right to cancel the authorization at any time, in writing, by contacting BCBSIL.
    –  I or anyone I authorize to represent me will receive a copy of this authorization upon request.
    –  Any cancellation will not affect the activities of BCBSIL before the date such cancellation is received by BCBSIL.
  • I present any statements and answers on this Application as FACTS. To the best of my knowledge and belief, they are true and complete. These facts are the basis of my Application.
  • The Application will become a part of the contract between BCBSIL and me.
  • My agent (if I have one) and I confirm that I have read and understood the Application.
  • I have reviewed the details of the plan I chose.
  • This individual or family plan is meant to be paid as my personal expense.
  • Only I or a family member, or an allowed third party as outlined in the Application will pay BCBSIL directly.
  • BCBSIL does not accept payments directly from third parties except from those listed on page 8 (family members, Required Entities, certain private nonprofit foundations).
  • If these rules are broken, any payments made by a third party will not be credited to my account or coverage. These payments may not be refunded to me. This may result in the cancellation of my coverage for nonpayment.

WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE FOUND GUILTY OF A FELONY IN A COURT OF LAW.

ACKNOWLEDGMENTS
BY COMPLETING AND SIGNING THIS FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:

  • This Application is not coverage. Coverage will not begin until (1) the effective date of the policy and (2) the first month's payment is made.
  • If I use an agent or broker, they cannot accept risks or change BCBSTX policies or rules.
  • If an agent, producer or broker was helping me to purchase an individual or family health or dental plan, BCBSTX may pay the broker a commission and/or other payment. If I want more detail about any payment to the agent or broker, I should ask the agent or broker.
  • If any person knowingly submits a false claim for payment of a loss or benefit or falsely misstates an important fact on this Application, coverage may be rescinded. This includes false claims or facts about me or any of my dependents. Rescission cancels the coverage back to the first day it became effective. I will be given at least 30 days´ written notice before my coverage or that of my dependents is rescinded.
  • My monthly premium will be calculated using factors approved by the State's Department of Insurance and other applicable State and Federal laws and regulations. Rates are calculated based on age, tobacco use and geographic rating factors. These factors are also used to calculate premiums for any dependents covered on my policy.
  • Coverage will start on the plan effective date only if the first monthly payment is received in full before that date.
  • I allow any of the following people or organizations to share my health information with BCBSTX or their authorized representative:
    • Health professionals, hospitals, or clinics
    • Other health or health‐related facilities
    • Government agencies
    • Pharmacy benefit managers, clearinghouses, or retail stores
    • Any other persons or firms required by law
    –  This information may include:
    • Copies of records about advice, care or treatment that were given to me and/or my dependents
    • Information about the prescription and use of drugs or alcohol (without limitation)
    • Information about mental illness
  • BCBSTX may review and research its own records for information.
  • BCBSTX will share collected information only as needed with medical entities to help manage my care.
  • Information shared with my authorization may be re-shared by BCBSTX as allowed or required by law. If such sharing is required, the person or agency getting the information will be responsible for protecting it.
  • This authorization is valid for two years from today, or until I cancel coverage.
    –  I have the right to cancel the authorization at any time, in writing, by contacting BCBSTX.
    –  I or anyone I authorize to represent me will receive a copy of this authorization upon request.
    –  Any cancellation will not affect the activities of BCBSTX before the date such cancellation is received by BCBSTX.
  • I present any statements and answers on this Application as FACTS. To the best of my knowledge and belief, they are true and complete. These facts are the basis of my Application.
  • The Application will become a part of the contract between BCBSTX and me.
  • My agent (if I have one) and I confirm that I have read and understood the Application.
  • I have reviewed the details of the plan I chose.
  • This individual or family plan is meant to be paid as my personal expense.
  • Only I or a family member, or an allowed third party as outlined in the Application will pay BCBSTX directly.
  • BCBSTX does not accept payments directly from third parties except from those listed on page 8 (family members, Required Entities, certain private nonprofit foundations).
  • If these rules are broken, any payments made by a third party will not be credited to my account or coverage. These payments may not be refunded to me. This may result in the cancellation of my coverage for nonpayment.

WARNING: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.

HMO Disclosure BY COMPLETING AND SIGNING THIS FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:

TEXAS DEPARTMENT OF INSURANCE REQUIRED DISCLOSURE NOTICE FOR ALL CONSUMER CHOICE HEALTH BENEFIT PLANS ISSUED IN TEXAS

Under Texas law, HMOs are permitted to market "Consumer Choice" plans, which do not have to comply with one or more state coverage requirements. They must also offer a plan that does comply with all state requirements. HMOs are required by law to obtain signatures of consumers showing they have been given this notice.

I have been informed that the consumer choice plan I am being offered does not include all of the health benefits usually required by Texas law. I understand that the following benefits are either excluded from the plan or provided at a reduced level:

DESCRIPTION OF THE STATE REQUIREMENTS REDUCED OR EXCLUDEDBENEFIT REDUCEDBENEFIT EXCLUDED
COPAYMENTS Section 11.506(2)(A), Subchapter F, Title 28 Texas Insurance Code: A reasonable copayment option may not exceed 50 percent of the total cost of services provided. A basic health care service HMO may not impose copayment charges on any enrollee in any calendar year, when the copayments made by the enrolled in that calendar year total 200 percent of the total annual premium cost which is required to be paid by or on behalf of that enrollee. The limitation only applies if the enrollee demonstrates that copayments in that amount have been paid that year.For some services and supplies, this plan may include cost-sharing that exceeds the limits imposed by the mandate.
DEDUCTIBLES Section 11.506(2)(B), Subchapter F,Title 28 Texas Insurance Code: A deductible must be for specific dollar amount of the cost of the basic, limited or single health care service. Except for a consumer choice benefit plan, an HMO may not charge a deductible for services received in the HMO's delivery network, except in cases involving emergency care and services that are not available in the HMO's delivery network.Deductibles may apply to some services provided by HMO Participating Providers in the HMO service area. Deductibles may apply to Professional Services, Inpatient Hospital Services, Outpatient Facility Services, Outpatient Lab and X-Ray Services, Rehabilitation Services and Habilitation Services, Maternity Care and Family Planning, Behavioral Health Services, Emergency and Ambulance Services, Extended Care Services, some Preventive Care Services, Dental Surgical Procedures, Cosmetic, Reconstructive or Plastic Surgery, Allergy Care, Diabetes Care, Prosthetic Appliances, Orthotic Devices, Durable Medical Equipment, Hearing Aids and Prescription Drugs.
LIMITATIONS Section 11.508 (d) Subchapter F, Title 28 Texas Insurance Code: A state-mandated health benefit plan defined in §11.2(b) of this title (relating to Definitions) shall provide coverage for the basic health care services as described in subsection (a) of this section, as well as all state-mandated benefits as described in §§21.3516 - 21.3518 of this title (relating to State-mandated Health Benefits in Individual HMO Plans, State-mandated Health Benefits in Small Employer HMO Plans, and State-mandated Health Benefits in Large Employer HMO Plans), and must provide the services without limitation as to time and cost, other than those limitations specifically prescribed in this subchapter.Benefit limits will apply to coverage for Home Health Services. Benefit limits will also apply to Rehabilitation Services and Habilitation Services, except for treatment of Acquired Brain Injury and Autism Spectrum DisorderNot Covered

I understand that if I buy a consumer choice plan, the HMO may deny or limit coverage for these services for me and anyone else covered by my health plan when the health needs of anyone covered under my plan changes. I understand that I can get more information about consumer choice plans from the Texas Department of Insurance (TDI) by visiting the TDI website at http://tdi.texas.gov/consumer/consumerchoice.html or by calling the TDI Consumer Help Line at 1-800-252-3439.

NOTE : The HMO issuing the policy must keep this disclosure statement and provide it to the commissioner of insurance on request. You have the right to a copy of this written disclosure statement free of charge. You must sign a new disclosure statement when you buy a consumer choice plan and each time your policy renews.

ACKNOWLEDGMENTS
BY COMPLETING AND SIGNING THIS FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:

  • This Application is not coverage. Coverage will not begin until (1) the effective date of the policy and (2) the first month's payment is made.
  • If I use an agent or broker, they cannot accept risks or change BCBSOK policies or rules.
  • If an agent, producer or broker was helping me to purchase an individual or family health or dental plan, BCBSOK may pay the broker a commission and/or other payment. If I want more detail about any payment to the agent or broker, I should ask the agent or broker.
  • If any person knowingly submits a false claim for payment of a loss or benefit or falsely misstates an important fact on this Application, coverage may be rescinded. This includes false claims or facts about me or any of my dependents. Rescission cancels the coverage back to the first day it became effective. I will be given at least 30 days´ written notice before my coverage or that of my dependents is rescinded.
  • My monthly premium will be calculated using factors approved by the State's Department of Insurance and other applicable State and Federal laws and regulations. Rates are calculated based on age, tobacco use and geographic rating factors. These factors are also used to calculate premiums for any dependents covered on my policy.
  • Coverage will start on the plan effective date only if the first monthly payment is received in full before that date.
  • I allow any of the following people or organizations to share my health information with BCBSOK or their authorized representative:
    • Health professionals, hospitals, or clinics
    • Other health or health‐related facilities
    • Government agencies
    • Pharmacy benefit managers, clearinghouses, or retail stores
    • Any other persons or firms required by law
    –  This information may include:
    • Copies of records about advice, care or treatment that were given to me and/or my dependents
    • Information about the prescription and use of drugs or alcohol (without limitation)
    • Information about mental illness
  • BCBSOK may review and research its own records for information.
  • BCBSOK will share collected information only as needed with medical entities to help manage my care.
  • Information shared with my authorization may be re-shared by BCBSOK as allowed or required by law. If such sharing is required, the person or agency getting the information will be responsible for protecting it.
  • This authorization is valid for two years from today, or until I cancel coverage.
    –  I have the right to cancel the authorization at any time, in writing, by contacting BCBSOK.
    –  I or anyone I authorize to represent me will receive a copy of this authorization upon request.
    –  Any cancellation will not affect the activities of BCBSOK before the date such cancellation is received by BCBSOK.
  • I present any statements and answers on this Application as FACTS. To the best of my knowledge and belief, they are true and complete. These facts are the basis of my Application.
  • The Application will become a part of the contract between BCBSOK and me.
  • My agent (if I have one) and I confirm that I have read and understood the Application.
  • I have reviewed the details of the plan I chose.
  • This individual or family plan is meant to be paid as my personal expense.
  • Only I or a family member, or an allowed third party as outlined in the Application will pay BCBSOK directly.
  • BCBSOK does not accept payments directly from third parties except from those listed on page 8 (family members, Required Entities, certain private nonprofit foundations).
  • If these rules are broken, any payments made by a third party will not be credited to my account or coverage. These payments may not be refunded to me. This may result in the cancellation of my coverage for nonpayment.

WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE FOUND GUILTY OF A FELONY IN A COURT OF LAW.

AUTHORIZATION AGREEMENT

Your premium is the monthly amount that must be paid for your health insurance plan. Keep in mind you may have other health care costs that are not part of your fixed monthly costs.

NOTE: Do not cancel any current coverage you may have until your Application is approved and your new plan is effective.Your first month's payment is due when you sign up. If you are signing up for a new plan, your application will not be processed until we receive your payment.

THIRD PARTY PAYMENT RULES BCBS accepts premium or cost-sharing payments for members from these four sources only:

  1. You
  2. Your family, or someone who has your Power of Attorney, a Legal Guardian or a Trust
  3. Authorized Entities Under the law, BCBS accepts payments from Authorized Entities. At this time, Authorized Entities include:
    1. Ryan White HIV/AIDS programs, under Title XXVI of the Public Health Service Act
    2. Indian tribes, tribal organizations and urban Indian organizations
    3. State and Federal government programs as described in 45 C.F.R. ? 156.1250.
  4. Private non-profit foundations that pay:
    1. for the entire coverage period of your contract,
    2. no matter your health status, and
    3. no matter what company or benefit plan you choose

Payments made by a third party that is not shown above will not be accepted for your account. This may end or cancel the coverage.

I understand:
  • My BCBS plan will not be a group health plan sponsored by an employer.
  • This coverage is not meant to be an employer-sponsored group health insurance plan in any way.
I agree:
  • My employer (if any) will not pay any part of my monthly bill or copays.
  • My employer (if any) will not pay me back for these payments now or in the future.

PAST DUE PAYMENT POLICY When you renew your Blue Cross and Blue Shield of IllinoisOklahomaTexas coverage or reenroll by selecting a new product, you will need to be current on the premium payments. Any past due premium payments for coverage that Blue Cross and Blue Shield of IllinoisOklahomaTexas provided will be due at the start of the new plan year, in addition to current premium charges. New coverage will not be effective until all such payments are made.

ELECTRONIC FUNDS TRANSFER (EFT) BILLING RULES

If you allow EFT, you understand and agree that BCBS and/or the company BCBS chooses to process payments may withdraw monthly payments from your checking or savings account in accordance with the terms below:

  • Payments are due on the last day of the month before the month of coverage.
  • Payment will be made as you choose on the next page.
  • Your bank or credit union will process these payments.
  • If the payment date falls on a nonbusiness day or a holiday, the payment will be taken on the next business day.
  • Please make sure you have enough money in your account when you submit this Application. If a payment is denied for non-sufficient funds (NSF), BCBS may try to process the charge again at any time in the next 30 days. BCBS will not pay you back for any fees your bank or credit union charges you for not having enough money in your account.
  • Both the bank or credit union and BCBS) reserve the right to end this payment program or your participation in it if payment is denied for NSF. This means payments would not be made automatically anymore. Coverage may stop (claims would not be paid) if you do not pay your monthly bill.
  • To change the bank or credit union these payments are paid from, you will need to give at least 15 days’ notice to BCBS) by telephone before a scheduled payment date.

PROXY STATEMENT

By purchasing a BCBS health plan, I become a member of Health Care Service Corporation, a Mutual Legal Reserve Company (HCSC). By signing this application, I ask the Board of Directors of HCSC to act on my behalf at all meetings of members of HCSC. I understand that:

This permission will apply to any company that replaces HCSC The Board of Directors may appoint someone to vote for me The annual meeting of members is scheduled to take place each year in the corporate headquarters (300 E. Randolph St., Chicago, IL 60601) on the last Tuesday of October at 12:30 p.m. Special meetings of members may be called if needed. Notice of any special meeting will be given within 30-60 days before the meeting.

My assignment of my member vote to the Board of Directors will be in effect:

Until or if I cancel it in writing at least 20 days before any meeting of members, or Unless I attend and vote in person at any meeting of members

Dental Coverage The Affordable Care Act (“ACA”) requires us to be reasonably assured that you and each member on this policy have or are seeking coverage for pediatric dental services that are essential health benefits. The Affordable Care Act requires these benefits even if there is no one on the policy who is eligible for these services.
Carriers can offer this required pediatric dental coverage to you through benefit plans called “Marketplace-certified stand-alone dental plans.” These plans are also known as Dental Qualified Health Plans or Dental QHPs.

By submitting this application, you are confirming that I/we already have coverage for pediatric dental essential health benefits through another policy. Our records will show that you have the pediatric Dental EHB from BCBS or another company.

ATTENTION FEMALE MEMBERS:

As a reminder, you can get OB-GYN care from your Primary Care Provider (PCP) or an OB-GYN.

Please Note:
- You don’t need a referral from your PCP to see an OB-GYN
- You won’t need to tell us your OB-GYN’s name before your visit.
- Some plans will cover your OB-GYN visits only if your OB-GYN is in your plan network

* required
IF ANY OF THE TELEPHONE NUMBERS I PROVIDE IN THIS APPLICATION ARE CELL PHONES, THEN I AGREE TO THE FOLLOWING TYPES OF CONTACTS:
IF ANY OF THE TELEPHONE NUMBERS I PROVIDE IN THIS APPLICATION ARE FOR RESIDENTIAL (LANDLINE) PHONES, THEN I AGREE TO THE FOLLOWING TYPE OF CONTACT:
You forgot to agree to the terms
To make or change your choices, you may:
  • Register for or log in to your account at bcbsil.com. Go to the top of the page and select Settings and then Preferences.
OR
  • Call Customer Service at the number on your member ID card. Your electronic delivery will continue through any policy renewals or changes. You can go back to paper delivery at any time with no penalty.
If you are enrolling in an HMO policy, by signing and submitting this application, you are agreeing to the following: BCBS will assign a PCPMedical Group for you. Once you become a member, you can change your PCPMedical Group at any time.

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Your Applications

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Adult members must be between the age up to
Primary applicant is required
Primary applicant age can only be up to years old
Spouse age can only be up to years old
Children are eligible up to years old
Primary applicant must be at least years old
Spouse must be at least year old
You won't be able to add children older than 25. You can start a new application for them after you finish yours. Questions? Read More Here
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Only one spouse is allowed. Please fix the relationship field.
If the Primary Applicant is a child, then only one applicant is allowed and other people would have to apply on their own.
If this is a mistake, then change the Primary Applicant's birth date. Otherwise please remove other applicants.
 

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Mailing Address
iHealthAgents
3501 N Southport Ave #207
Chicago, IL 60657