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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
any physician or other health care professional, hospital or
other health care facility, counselor, therapist, or any other
medical or medically related facility or professional who has
provided any services to me or any of my dependents applying
for or having membership in any Kaiser Foundation Health Plan
product (each, an "Applicant") to give Kaiser Foundation
Health Plan of Georgia, Inc., or its affiliates ("Kaiser
Permanente"), their respective agents, employees, designees,
or representatives, including my Kaiser Permanente agent or broker,
any and all information or records relating to medical history,
medical examinations, services rendered, or treatment given,
including treatment for alcohol abuse, substance abuse, mental
or emotional disorders, sexually transmitted diseases, HIV (Human
Immunodeficiency Virus) status, AIDS (Acquired Immune Deficiency
Syndrome), or ARC (AIDS-Related Complex) ("Medical Information")
of the Applicant. However, Medical Information does not include
genetic information or "Psychotherapy Notes" (as defined
by 45 C.F.R. B 164.501). I understand
that such Medical Information may be requested and used in connection
with the review, investigation or evaluation of enrollment or
of any claim for benefits after enrollment.
I also authorize Kaiser Permanente to disclose any and all such
Medical Information related to any Applicant to any health care
provider, health care plan service, self-insurer or insurance
company for the purpose of review, investigation or evaluation
of enrollment or of any claim for benefits after enrollment.
I will sign new authorizations, ir necessary, so that, in connection
with the review, investigation or evaluation of enrollment or
of any claim for benefits, Kaiser Permanente may request, use
and disclose Medical Information and "Psychotherapy Notes."
Medical Information, once disclosed, may no longer be protected
by Federal privacy law and may be further disclosed.
This authorization
is effective immediately and will remain in effect for a period
of thirty (30) months, except that it will remain in effect for
use by Kaiser Permanente in connection with the review, investigation
or evaluation of any claim for benefits for an Applicant if that
Applicant is still a member of any Kaiser Foundation Health Plan.
A photocopy of this authorization is as valid as the original,
and I and my Kaiser Permanente agent or broker are entitled to
receive a copy of the form. I may revoke this authorization (to
the extent applicable to my Medical Information) at any time
prior to its expiration. However, revocation is noteffective
to the extent that Kaiser Permanente has already taken action
in reliance on it, or for so long as Kaiser Permanente my contest
my enrollment or of any claim for benefits. I understand that
the instructions for revoking authorizations are in Kaiser Permanente's
Notice of Privacy Practices.
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.
For more information, call 1-800-656-2298. 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.
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. Date:
By
entering my name here, I the primary applicant's spouse, am submitting
a legal, binding, and valid signature. Date:
By
entering my name here, I the dependent(over 18 years of age)
am submitting a legal, binding, and valid signature. Date: |