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Application Agreement
I hereby
apply for enrollment for myself and eligible family dependents
listed on this form, and I agree that the information listed
is correct. Upon acceptance to the Health Plan, my credit card
will be charged, and my coverage will begin on the first day
of the month as assigned by Kaiser Health Plan.
I authorize
Kaiser Foundation Health Plan of Georgia, Inc. (Kaiser Permanente)
and Kaiser Permanente Insurance Company (KPIC) to review existing
protected health information (PHI) and history of care provided
to me or my minor dependents for a period of 7 years preceeding
the date of this application for membership in the Personal Advantage
Program. This authorization applies to information about any
and all types of care that is reasonably related to determining
my/our eligibility for membership in the Personal Advantage Program,
including but not limited to, diagnosis and treatment of mental
health, alcohol/chemical dependency, HIV, AIDS, AIDS-related
conditions, medication history, pharmacy data, and prescription
history.
If accepted
as a Personal Advantage member, I understand that Kaiser Permanente
and KPIC may, without limitation and including all categories
of care stated above, review and use my PHI following my/our
actual enrollment and intial usage of services in order to confirm
consistency with the information I submitted in this application
or for such other purposes as permitted by federal and/or state
laws or regulations. I understand that Kaiser Permanente and
KPIC will not re-disclose any information received except with
my written consent, or as permitted by federal and/or state laws
or regulations. I understand that PHI disclosed to others may
no longer be protected by Kaiser Permanente policy or the Health
Insurance Portability and Accountability Act of 1996 (HIPAA).
This authorization is effective for a period of 30 months from
the date this application is signed. I understand that I may
revoke this authorization in writing at any time, except to the
extent that action has been taken based on this authorization.
I understand that revocation of an authorization used to secure
a policy of insurance, including health coverage from Kaiser
Permanente, is not permitted during the period of time the insurer
may contest the policy issued or a claim under the policy. I
further understand that to revoke this authorization I must send
a written revocation notice to: Kaiser Foundation Health Plan
of Georgia, Inc., Personal Advantage Underwriting Department,
3495 Piedmont Road, Atlanta, Georgia, 30305.
NOTICES:
1. Any intentional material
misstatement or omission of information may void your coverage
and/or the coverage of your family members. (If you are unsure
of your medical condition, please ask your current or previous
physician to clarify your specific condition).
2. YOU
MUST IMMEDIATELY INFORM US if your health status or current medication
changes at any time before your membrship in Personal Advantage
becomes effective. Failure to inform us of such changes can void
your membership. You can choose to update your application information
by telephone (404)364-7001, by fax (404)365-4146, or by writing
us at Kaiser Permanente Personal Advantage; 3495 Piedmont Road,
NE; Building 9; Atlanta, GA 30305. All written and fax correspondence
must be signed and dated.
3.
AFTER
the effective date of this coverage, Health Plan may rescind
your coverage and your dependent's coverage retroactively to
the effective date (1) based on updated information, (2) upon
learning that you failed to provide updated information, OR (3)
upon learning that you intentionally provided any incorrect or
incomplete answers on this application or in communications regarding
it. If your coverage is rescinded, you will be billed for all
services you received.
4. Georgia residents who
do not qualify for Personal Advantage and are not current Kaiser
Foundation Health Plan members may be eligible to participate
in the State of Georgia Health Insurance Assignment System, a
state-sponsored guaranteed-issue health care coverage program
in which Kaiser Permanente participates. Georgia residents who
do not qualify for Personal Advantage and who are current Kaiser
Foundation Health Plan members can choosed to be considered for
our conversion products, one of which is available to HIPAA-qualified
individuals. If you wish to exercise that option, please contact
our Customer Service Department at (404)261-2590 to obtain an
application.
TO THE APPLICANT: You or your authorized representative
may request a copy of your completed application. For more information,
please call (404)364-7001.
I authorize the disclosure of
premium billing, claim payment, and comission information to
my broker of record and my spouse (if applicable) to expedite
the servicing of my account.
IMPORTANT:
I have read and
understand all of the above conditions and terms.
By entering my
name here, I the primary applicant am submitting a legal, binding,
and valid signature.
By
entering my name here, I the primary applicant's spouse, am submitting
a legal, binding, and valid signature.
By
entering my name here, I the dependent(over 18 years of age)
am submitting a legal, binding, and valid signature. |