Health Insurance Intake Form

The undersigned acknowledges this form is an application for membership and that final acceptance is based on review by HC Data Consulting, LLC. If all requirements are met, new members will be granted full access to all available benefits.

By signing this application, I understand the following: That if any information submitted on this form constitutes fraud or there is an intentional misrepresentation of the material fact, the plan may rescind healthcare coverage. In any such case, I understand that the plan will return any contributions that have previously been paid as to the rescinded coverage, minus administrative expenses and claims paid. I certify that the statements are true and correct to the best of my knowledge. I understand that this form is used for information purposes only and does not bind coverage. I understand the AAHP gathers this information for statistical and actuarial uses only and it will not be used in connection with decisions or actions regarding employment. That if I am a resident in Michigan, I do not have to provide information regarding height or weight, and that this in compliance with requirements for GINA. That I have read the Client Privacy Notification provided to me in this application. That as a prospective member, I have the right to request restrictions on how my protected health information is used, and that the AAHP is not required by law to grant this request, but if the request is granted, the AAHP is bound by this agreement. I also understand that I have the right to revoke this consent in writing, except to the extent the AAHP Program has already used or disclosed the protected health information in reliance upon my consent. I further understand that the AAHP program will notify me the member of any health or enrollment related changes that occur after signing this form, up to the effective date of coverage.

Thank you for completing the requested information. Any information, including non-public personal health information, such as name, address and social security number, including detailed protected health information provided will be used for the sole purpose of providing a risk assessment to the health plan that will provide a health care benefit quote to your employer. The AAHP's actuary is a legally contracted underwriter acting as a Business Associate to the AAHP Program and is subject to certain provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. The AAHP's actuary and underwriter will not sell, license, transmit or disclose this information outside of their offices except as: a) necessary for them to provide the services on behalf of the health plan, b) expressly authorized by you, c) necessary for backup documentation purposes, or d) required by law.

The undersigned hereby acknowledges, understands, and agrees that if I enroll in health insurance coverage or make a payment for coverage between the 21st and 25th of any month for coverage that starts on the 1st day of the following month (the "Effective Date"), it may take up to ten (10) business days after my Effective Date for my enrollment to be fully activated (the "Activation Period") in the systems used by the third-party administrator ("TPA"), pharmacies, and providers. During the Activation Period, I further understand that: I may not be able to access or use some or all of my plan benefits. Providers and pharmacies may not be able to verify my coverage at the time of service. Claims for services I receive during the Activation Period may not be submitted or processed until my enrollment has been fully activated, and healthcare providers may need to wait up to ten (10) business days after my Effective Date before submitting claims for payment. I may still seek medical care, including emergency services, during the Activation Period, but I should expect possible delays in claim submission and processing until activation is complete.

The undersigned understands and acknowledges that the membership and health plan offered through this enrollment process are not available to residents of the State of Washington. The undersigned hereby represents, warrants, and attests that: (1) the undersigned is not a resident of the State of Washington; and (2) no dependent being enrolled for coverage is a resident of the State of Washington. The undersigned acknowledges that eligibility for coverage through this enrollment process is conditioned upon the accuracy and completeness of all information provided, including the residency information provided to Enroll Prime. The undersigned agrees to promptly notify Enroll Prime if the undersigned, or any dependent enrolled for coverage, becomes a resident of the State of Washington at any time before coverage becomes effective or during the coverage period. Failure to provide such notice may constitute a material misrepresentation and may result in the remedies described herein. The undersigned further understands and agrees that any false, misleading, or incomplete statement regarding residency may result in denial of enrollment, rescission or termination of coverage, or other action permitted under the applicable plan terms and governing law.