X5119 smone health ap oh r7_06

MMO USE ONLY
INSTRUCTIONS: All questions must be answered. Incomplete applications will be returned.
Section I: Contract Holder Information
Marital Status: ▫ Single ▫ Married ▫ Divorced ▫ Separated ▫ Widowed Marriage Date: / / Reason for Application: ▫ Applying for new coverage ▫ Applying for dependent only coverage ▫ Applying for change to current coverage
LIST BELOW ALL INDIVIDUALS TO BE COVERED
Section II: Federal and Ohio Open Enrollment Eligibility
1. ▫ Yes ▫ No Are you a Federally Eligible Individual or applying for coverage under the Ohio Open Enrollment requirements?
If Yes, STOP HERE. SuperMed One® is NOT a Federally Eligible or Ohio Open Enrollment product. For an information and application packet, please call Medical
Mutual at 800/242-1936. SuperMed One may affect your status as a federally eligible individual. Visit the ohioinsurance.gov Web site for more information.
Section III: Products
SuperMed One Standard Plans:
SuperMed One HSA Plans:
SuperMed One Value Plans:
SuperMed One Short Term:
Optional Coverage1:
Desired effective date: _________ / _________ /_________
1Dental and Vision coverage can be purchased as a stand-alone product. One year of premium is due when purchased as a stand-alone product.
Section IV: OTHER COVERAGE INFORMATION
1. ▫ Yes ▫ No Does ANY PERSON TO BE COVERED have any other type of health insurance (Accident, Medicare, Medicaid, etc.) or is ANY PERSON
TO BE COVERED currently applying for any other health insurance? If yes, please complete the following:
NAME OF INSURANCE COMPANY
2. ▫ Yes ▫ No Has ANY PERSON TO BE COVERED been insured by another health plan within the last 63 days? If yes, please complete the following:
NAME OF INSURANCE COMPANY
DATES OF COVERAGE
Section V: MEDICAL ELIGIBILITY
IMPORTANT: SuperMed One is a medically underwritten product. Please answer all medical eligibility questions completely. Use additional paper, if
necessary. Incomplete applications will be returned.
A. ▫ Yes ▫ No Are YOU, your SPOUSE or any DEPENDENT currently pregnant, an expectant parent, or in the process of adoption (even if not named on
this application)?
B. ▫ Yes ▫ No Has ANY PERSON TO BE COVERED taken any prescription medication, or been prescribed medication by a physician, during the past
MEDICATION AND DOSAGE
MEDICAL CONDITION
C. ▫ Yes ▫ No Has any insurance company refused, restricted or charged more than a standard rate for health coverage on ANY PERSON TO BE
COVERED?
REFUSAL OR RESTRICTION
MEDICAL CONDITION
Section V: MEDICAL ELIGIBILITY (continued)
D. ▫ Yes ▫ No Does ANY PERSON TO BE COVERED have a condition covered by Workers' Compensation?
WORKERS’ COMPENSATION NUMBER
MEDICAL CONDITION
E. ▫ Yes ▫ No In the past twelve months, has ANY PERSON TO BE COVERED had any of the following symptoms: unexplained weight loss,
night sweats, persistent fever or cough, malaise, prolonged fatigue, chronic/recurrent skin rashes or lesions, recurrent episodes of diarrhea, lymph node enlargement, unexplained recurrent headache, or unexplained pain or discomfort? SYMPTOMS
F. ▫ Yes ▫ No In the past twelve months, has surgery, diagnostic testing or medical treatment been recommended or considered for any person to be REASON RESULTS
G. For each person to be covered, provide the name of their physician, and the last time they saw their physician: NAME PHYSICIAN NAME
REASON RESULTS
Section V: MEDICAL ELIGIBILITY (continued)
H. Has ANY PERSON TO BE COVERED within the past ten years been treated for, diagnosed as having, hospitalized, had surgery, been recommended for
future surgery, diagnostic testing or medical treatment or thought you should seek medical advice for any of the following conditions? Each condition CONDITION
CONDITION
CONDITION
30. Cystitis (Chronic or interstitial) ▫ I. ▫ Yes ▫ No In the past ten years, has ANY PERSON TO BE COVERED been treated, diagnosed, or consulted a physician, psychotherapist, counselor,
or any other provider, for any illness, injury, medical abnormality or mental or emotional condition not stated in questions A-H?
Section V: MEDICAL ELIGIBILITY (continued)
J. ▫ Yes ▫ No In the past ten years, has ANY PERSON TO BE COVERED received any abnormal results in any of the following tests for conditions not
already described: blood work, laboratory results, x-ray, EKG, blood flow studies, MRI scan or CT scan? K. ▫ Yes ▫ No In the past ten years, has ANY PERSON TO BE COVERED undergone surgery (including cosmetic surgery), been confined to a hospital, or
treated in an emergency room for conditions not already described? L. If any Medical Eligibility questions (H1-H98, I, J or K) are checked “YES”, please explain below, (use additional paper, if necessary).Indicate all details of the injury, ailment or condition. Include items such as specific location of condition (example: right knee), diagnosis, type of treatment and hospitalization.
PATIENT FIRST
DETAILS OF CONDITION
MEDICATION
HOSPITALIZED
QUESTION NUMBER
DOSAGE AND DATES
PHYSICIAN NAME
AND CURRENT STATUS
OR SURGERY?
High cholesterol controlled by medication. Section VI: BILLING INFORMATION
CHOOSE ONE:
▫ HOME Receive monthly premium billings
▫ FINANCIAL INSTITUTION Have monthly automatic premium withdrawls
If you wish to be billed through your financial institution, please complete the following authorization: I authorize Medical Mutual of Ohio to initiate premium deductions from my account. The authorization will remain in effect until Medical Mutual of Ohio and my financial institution have received written notification from me within a reasonable time period to allow termination of the deduction.
Premiums are to be deducted from: ▫ Checking (Please note: Not all Financial Institutions allow deductions from a savings account. Please verify this information with your financial institution.) Name and branch of bank/financial institution (must be in Ohio) Please attach a voided check for checking account or a deposit slip for savings account in order for our office to verify the bank information.
▫ CREDIT CARD Have monthly premium billed to credit card
If you wish to be billed through your credit card, please complete the following authorization: ▫ Mastercard ▫ Visa ▫ LIST BILLING THROUGH EMPLOYER is available only to employees of a common employer who has agreed to collect the premiums on a
monthly basis through payroll deduction and where the employer is not paying any portion of the premium.
▫ DIFFERENT BILLING ADDRESS Have home billing sent to a different address
If your mailing address is different than your permanent address, complete the following: TACH VOIDED CHECK
OR DEPOSIT SLIP HERE
FOR OFFICE USE ONLY
Section VII: TERMS AND CONDITIONS
I hereby apply under Medical Mutual of Ohio's Group Trust for the coverage indicated on this application. I further agree to participate in such trust and
agree to be bound to the relevant terms of the Master Group Contract(s) and the Trust Agreement.
1. I authorize release of information, without limitation, from any medical/medically related facility, prior health insurance carrier, the Medical Information Bureau, Inc. (MIB), government agency or person to Medical Mutual of Ohio (MMO) and/or any affiliates or division of MMO: (a) to evaluate this application; (b) to adjudicate claims submitted on behalf of me or my dependents; (c) for utilization review programs to monitor health services or quality improvement activities and/or; (d) for credentialing purposes. I authorize MMO to provide a photocopy of this release to any physician or medical institution to obtain records for the purposes stated above. This authorization will be valid for a period of two and one-half years for the purpose of collecting information regarding this Application.
2. I agree that a medical examination of me may be required in connection with this Health Insurance Application. I further agree that I, as the Applicant, will be responsible to pay for the medical examination and/or the release of any and all records on behalf of myself, my spouse, and/or the listed dependents.
3. By signing below, I represent and warrant as follows: (a) I have thoroughly read and understand this Health Application and the questions asked herein; (b) I have answered each and every question set forth in this Application; (c) all of my answers to each of the questions are accurate, complete and true and (d) I did not sign a blank or partially completed Application. I agree that MMO, in their sole discretion, may rescind my policy at any time on the basis of any untrue, inaccurate or incomplete answer to any question in this Application, or any misrepresentation, omission or concealment on this Application, whether intentional or otherwise. I further agree that if a policy is issued, it will be issued by MMO in full reliance and in consideration of the information, answers and statements contained herein. I understand that this policy will be medically underwritten.
4. I have read the sales materials and understand the plan benefits, exclusions, and limitations as outlined therein. I acknowledge that the managed care features of this health insurance policy (such as the preferred provider organization network) have been explained to my satisfaction. I also understand that I may review a copy of the Master Group Contract(s) and Trust Agreement upon making such a written request to MMO.
5. No issuance, waiver, modification or change of policy or any of MMO rules or amendments shall be binding upon MMO unless it is in writing and signed by an authorized officer of MMO, as applicable.
6. Notice: Certain Pre-Existing Condition limitations will apply.
7. I represent that neither I nor my spouse are receiving any form of reimbursement or compensation for this coverage from any employer.
8. I also understand that information submitted with this application may require further medical underwriting. If that underwriting discloses additional medical risk I understand that there may be a significant change in the rate charged for this coverage or in certain cases, the coverage may be rescinded. A permanent ID card will be issued following the final review and acceptance of the application.
9. I understand and agree that I am solely and exclusively responsible for the truth, accuracy and completeness of all of the answers contained in this application. I understand and agree that no agent or broker who may be assisting in the completion of this application has any authority (a) to waive any answer or any portion of any answer to any question on this application or any information MMO requests, (b) to advise me that I am not obligated to disclose any condition of which I am aware concerning my health or the health of any dependent included on the application, (c) to make any representation concerning health benefits that are inconsistent with, or different from, any written information provided by MMO or (d) to bind MMO in any way by making any statement, promise or representation that is not set out in writing in this application or regarding eligibility, benefits or issuance of a policy, (e) to answer any questions in, or insert any information on, this Application on my behalf, or (f) to approve coverage.
10. I understand and agree that I am responsible for disclosing all information required by this application, including but not limited to all health conditions and diagnoses of which I am aware. I understand and agree that MMO has the exclusive right to determine whether a particular condition or diagnosis is significant, that I do not have the right to evaluate whether a condition or diagnosis should or should not be disclosed on this application and that I am obligated to disclose even those conditions or diagnoses that I do not believe are significant or important.
11. My dependents and I understand and agree that any information obtained will not be released by the Company to any person or organization except to reinsuring companies, the MIB, or other persons or organizations performing health care operations or business or legal services in connection with any application, claim, or as may be otherwise lawfully required, or as we may further authorize. If a Consumer Reporting Agency is used, I (we) may request to be interviewed in connection with the preparation of the report. Once personal and health (including medical, dental, and pharmacy) information is disclosed pursuant to this authorization, it may be redisclosed by the recipient and the information may not be protected by federal and state privacy requirements. A copy of this authorization request is available to me or my legal representative upon written request. A photographic copy of this authorization shall be as valid as the original. This authorization shall be valid for a period of two and one-half years. I have the right to revoke this authorization at any time. To revoke this authorization, I must do so in writing and send my written revocation to MMO's Privacy Office. The revocation will not apply to information that has already been released in response to this authorization. The revocation may adversely affect my application, a claim or a pending insurance action. The revocation will become effective after it is received by MMO's Privacy Office.
I am signing this Health Application on my own behalf and on behalf of all listed dependents. An unaltered copy of this authorization is as valid as the original. I understand that I should not cancel any current health insurance coverage until you receive an approval letter and insurance policy from MMO.
____________________________________________ ___________ ________________________________________________________ Contract Holder’s or Guardian’s Signature Guardian’s Social Security Number (if child only policy) _____________________________________________ ___________ _________________________________________ ___________ _____________________________________________ ___________ _________________________________________ ___________ Section VIII: HOW DID YOU HEAR ABOUT SUPERMED ONE? (CHECK ONE)
4. Advertisement in newspaper, magazine, etc.
WARNING: Any person who, with intent to defraud or knowing that he is facilitating fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement is guilty of insurance fraud. (Ohio Revised Code Section 3999.21).

Source: http://www.brownraybourn.net/supermed1application.pdf