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  • No one applying for coverage is in jail.
  • I will notify the insurer if anything on this application changes. I can do this through the federal marketplace. I understand a change could affect our eligibility for plans and subsidies.
  • I give permission to the federal marketplace to access my tax returns for up to 5 years to verify my income for premium tax credit purposes. I can revoke this permission at anytime.
  • 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.
  • If anyone on this application enrolls in Medicaid, I'm giving the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I'm also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.
  • If a child on this application has a parent living outside the home, I know I'll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell the agency and I may not have to cooperate.
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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:

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claim for payment of a loss or benefit or falsely misstates an important fact on this Application, coverage may be rescinded.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.

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.


ATTENTION FEMALE MEMBERS:
In selecting your Medical Group, remember that your Medical Group’s network may affect your choice of OB/GYN. You have the right to receive services from an OB/GYN without first obtaining a referral from your Medical Group. However, if your Medical Group is part of a limited provider network (LPN), the OB/GYN from who you receive services must belong to the same LPN as your Medical Group. This is another reason to make certain that your Medical Group’s network includes the specialists – particularly the OB/ GYN – and hospitals that you prefer. You are not required to designate an OB/GYN. You may elect to receive OB/GYN services from your Medical Group.

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.

AUTHORIZATION AGREEMENT Required for Bank/Financial Institution Draft Payments Only
I request and authorize BCBSIL and/or its designee to obtain payment of monthly premium amounts becoming due on the last day of the month prior to the following month’s coverage by initiating charges from my checking or savings account in the form of checks, share-drafts, or electronic debit entries, and I request and authorize the Financial Institution named below to accept and honor the same from my account. If the draft date falls on a non-business day or a holiday, the premium payment will be deducted from my account on the next business day. If an ACH Transaction from my account is rejected for Non-Sufficient Funds (NSF), I understand that BCBSIL may at its discretion attempt to process the charge again within 30 days. I also understand that both the Financial Institution and BCBSIL reserve the right to terminate this payment program and/or my participation therein. To change the Financial Institution these payments are paid from, I understand that I will need to provide at least 15 days advance notice to BCBSIL by telephone prior to a scheduled withdrawal date.
Please complete the following – print or type information
I authorize BCBSIL to deduct the premium payments from my checking or savings account.
Please ensure adequate funds are available at the time of Application. BCBSIL is not responsible for fees incurred due to insufficient funds.

NOTE: Cashing of the Premium Payment does not constitute approval of this Application. If this Application is not approved, the Premium Payment will be returned to the Primary Applicant and neither the Primary Applicant nor any other person applying for coverage under this Application shall be entitled to benefits or coverage. Policy on third-party payments. BCBSIL only accepts premium and cost-sharing payments from: (1) the Applicant; (2) the Applicant’s family; (3) Required Entities (the entities the law requires BCBSIL to accept premium and cost-sharing payments from, which currently are Ryan White HIV/AIDS programs, under title XXVI of the Public Health Service Act, Indian tribes, tribal organizations and urban Indian organizations; and State and Federal government programs, as described in 45 C.F.R. § 156.1250); and (4) private non-profit foundations that make premium or cost-sharing assistance available to the Applicant: (a) for the entire coverage period of the Applicant’s Contract, (b) regardless of the Applicant’s health status, and (c) cannot condition assistance on enrollment with a particular issuer or in a particular benefit plan. BCBSIL does not accept premium and cost-sharing payments from any other third party. A violation of this policy may result in premium and cost-sharing payments paid by a third party not being credited to the Applicant’s account or coverage, which may result in the termination or cancellation of coverage. In addition, I understand that the coverage for which I am applying is not an employer-sponsored group health insurance plan and is not intended, in any way, to be an employer-sponsored group health insurance plan. I certify that my employer, if any, will not contribute any part of the premium, or provide reimbursement for any part of the premium for this coverage, now or in the future. When you renew BCBSIL coverage or reenroll by selecting a new product, you will need to be current on your premium payments. Any past due premium payments for coverage we provided will be due at the beginning of the new plan year in addition to current premium charges. New coverage will not be effective until all such payments are made.

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