B CDE Regence BlueCross BlueShield of Oregon Oregon Individul nd Fmily Plns Blue Selections Premier Blue Selections Plus Blue Selections Bsic Regence HS Helthpln nd Individul Dentcre OREGON PPLICTION ND STNDRD HELTH STTEMENT Thnk you for selecting Regence BlueCross BlueShield of Oregon s your individul helth pln insurnce compny. www.regence.com Plese return this ppliction to: Regence BlueCross BlueShield of Oregon ttn: Individul Enrollment Services, Mil Sttion E-8U P.O. Box 1271 Portlnd, OR 97207-1271 Customer Service 1 (800) 365-3155 Underwriting 1 (888) 671-2950 Plese Note: These plns re not portbility plns. If you re pplying for portbility coverge following termintion of group helth benefits through Regence BlueCross BlueShield of Oregon, plese cll 1 (800) 365-3155 to obtin portbility informtion. FOR OFFICE USE ONLY dditionl telephone informtion received by Regence BlueCross BlueShield of Oregon
Section 1 - Instructions Plese red crefully. Use ink to complete nd sign this ppliction. n ppliction completed in pencil will be returned to you. Mke sure ll sections of the ppliction re nswered completely. If you need ssistnce completing this ppliction, plese contct your gent or cll Sles t 1-888-REGENCE (734-3623). SELECT ONE MEDICL PLN PER PPLICTION. Section 2 - Pln Selection MEDICL I m pplying for: New enrollment Chnge to my existing individul pln or deductible ddition of spouse/domestic prtner or dependent to my existing policy. (signture(s) required on pge 6) Child-only (ges 0-17). Complete seprte form for ech child on his or her own pln. Choose pln nd deductible below. BLUE SELECTIONS PREMIER DEDUCTIBLES: Medicl BLUE SELECTIONS PLUS DEDUCTIBLES: Medicl BLUE SELECTIONS BSIC DEDUCTIBLES: Medicl $1,000 $1,000 $1,000 $2,500 $2,500 $2,500 $5,000 $5,000 $5,000 $7,500 $10,000 REGENCE HS HELTHPLN DEDUCTIBLES: Medicl Single/Fmily $1,500/$3,000 $2,500/$5,000 $3,500/$7,000 Uses Prticipting Providers on the Preferred Provider Pln Network. Uses Prticipting Providers on the Preferred Provider Pln Network. DENTL (optionl) Uses Prticipting Providers on the Preferred Provider Network. Uses Prticipting Providers on the Prticipting Provider Network. I wish to enroll in the optionl Individul Dentcre pln for n dditionl monthly premium. Disenroll ll fmily members on my policy from Individul Dentcre. I understnd tht I/we cnnot reenroll for 12 months. Plese note: Individul Dentcre must be purchsed with one of our Blue Selections or Regence HS Helthpln medicl plns. Dentl only coverge is not vilble. If selected, Individul Dentcre must be dded for ll pplicnts listed on this form. (Plese initil) "My employer is not contributing to or pying the premium for this individul policy (including cfeteri plns)." Individul benefit plns re not intended for sle s n employer-sponsored helth benefit pln for employees. For informtion on smll employer helth benefit plns, contct the Regence BlueCross BlueShield of Oregon (Regence BCBSO) Group Sles deprtment t 1 (800) 452-7278. Effective dtes re ssigned by Regence BCBSO on the 1st or the 15th of the month following cceptnce nd pprovl. If you wish enrollment to begin on dte in the future (not more thn 90 dys from the dte you signed this form). Plese indicte tht dte here How did you her bout Regence BCBSO? Plese check the box tht best describes how you herd bout us. Friend gent Direct miling Web site Other Pge 1
Section 3 - Enrollment Informtion LIST LL ELIGIBLE FMILY MEMBERS TO BE COVERED Lst of Fmily Member First, Middle Initil Sex ge Height Weight Birthdte Socil Security Number pplicnt Spouse Certified Domestic Prtner Non-Certified Domestic Prtner * Child Child Child Explin the reltionship to the pplicnt for ny person(s) listed bove whose lst nme is different from the pplicnt's. We my request Certificte of Dependency form. *Non-Certified Domestic Prtner must submit n ffidvit of Domestic Prtnership. OREGON RESIDENCE DDRESS E-mil ddress (will not be disclosed outside of the compny) Residence Street ddress PO Box (if pplicble) City, Stte, Zip Code Home Phone Number Work Phone Number County ( ) ( ) Office Use CO Code BILLING DDRESS (complete only if billing should be sent to n ddress other thn listed bove) c/o ddress Reltionship to pplicnt City, Stte, ZIP Code Section 4 - Other Coverge Informtion 1. re you or ny dependents who re pplying for coverge currently covered on ny group, individul or self-insured medicl pln? Yes No If yes, do you intend to replce your current pln with this contrct? Yes No 2. re you currently enrolled in Regence BCBSO Individul medicl pln nd do you wish to cncel tht coverge? Yes No If you nswered yes, plese sign the sttement below: I wish to terminte my individul medicl coverge from Regence BCBSO on the effective dte of this individul policy. Signture Dte Regence BCBSO Individul Plns contin 6-month preexisting condition limittion period, nd 12 month exclusionry period for specific services. Plese provide the following informtion for ll pplicnts, nd ttch copy of your Certificte of Coverge from your current or prior crrier or similr document showing the beginning nd ending dtes of your current coverge, if pplicble. 1. 2. 3. 4. 5. OFFICE USE ONLY (First, Lst) Birthdte Insurnce Compny Policy Number Dtes of Coverge Dte Coverge Begn MM/DD/YYYY Dte Coverge Ended (indicte ctive if you re currently covered) MM/DD/YYYY Type of Coverge Employer Group Individul Medicre COBR High Risk Pool Other (describe) Group Number & Pkg. Identifiction Number Contrct Effective Dte Bill Period gent Number Pge 2
Section 5 - Oregon Stndrd Helth Sttement Hs ny insurnce compny, within the lst five yers, postponed, refused, restricted or incresed premium for life or helth insurnce coverge for helth resons for you or ny of your fmily members to be covered? Yes No If "yes", indicte nme of person ffected, reson for ction, nd nme of insurnce compny Notice to pplicnt: You re not required to disclose ny informtion on ny prt of this ppliction bout genetic testing or genetic informtion relting to you or to ny blood reltive. You re not required to disclose ny decision by n insurnce compny tht is bsed on genetic test or on genetic informtion. Plese mrk "Yes" or "No" for ech item (for you nd ny fmily members requesting coverge). Provide detils on Pge 5 to ny questions nswered "Yes." (For the purpose of these questions, chronic mens persistent, continuous, periodic, or combintion of ny of these terms.) Within the lst five yers, hs nyone listed on this ppliction hd ny medicl dvice, dignosis, cre, or tretment, including prescribed medictions, recommended or received from licensed helth cre professionl; or hd ny illness, ilment, injury, helth problem, symptoms, physicl impirment, surgery or hospitl confinement relted to ny of the following conditions: YES NO 1. IDS, RC, HIV positive 26. High cholesterol (if "Yes", record lst reding 2. lcohol/chemicl/drug buse/hbit on pge 5). 3. nemi/chronic ftigue 27. High blood pressure (if "Yes", record lst reding on pge 5). 4. ppendicitis/chronic bdominl pin 28. Kidney/kidney stones 5. Bck/neck/spine 29. Knee/shoulder/hip/other joints 6. Birth defect/congenitl deformities 30. Liver condition/heptitis 7. Bldder/urinry trct 31. Lupus, chronic muscle pin, muscle injury 8. Blood/circultory or disese, or fibromylgi 9. Bone/orthopedic 32. Mentl/emotionl condition/depression 10. Brin disese or injury/concussion 32b. Therpy/counseling within lst 5 yers 11. Brest (lumps or msses) (if "Yes", record dte of lst session on pge 5). 12. Cncer 33. Neurologicl condition/disese/injury 13. Chemotherpy/rdition tretment 34. Phlebitis/blood clot 14. Colon/rectum/intestine/bowel 35. Osteorthritis/osteoporosis/osteopeni 14b. Blood in stool 36. Prostte/elevted PS/prosttitis 15. Convulsion/seizures/epilepsy 37. Reproductive system disorder/infertility 16. Dibetes/sugr in urine 38. Chronic respirtory/lung condition 17. Chronic er/nose/throt/tonsil condition/disese/disorder 18. Eting disorders such s, but not limited to, norexi or bulimi 19. Emphysem/sthm/chronic lung disese (COPD) 20. Endocrine/glnd/hormone system 21. Disese or injury of eye/ctrct/glucom 22. Gllbldder/pncretic disese 23. Chronic hedches/migrines 24. Hert/chest pin/ngin 25. Herni 39. Rheumtoid rthritis 40. Sexully trnsmitted disese(s) 41. Skin condition, bnorml or cncerous moles or eczem/cysts/cncer 42. Sleep pne/chronic sleep disorder 43. Stomch disorders/ulcer/cid reflux 44. Stroke/prlysis/seizures 45. Tumors 46. TMJ/jw joint 47. Weight fluctution (+/-20 lbs.) 48. Cosmetic surgery/implnts, use of prosthetic devices/limbs YES NO Pge 3
Section 5 (continued) - Oregon Stndrd Helth Sttement 49. Hs ny person on this ppliction used tobcco products in ny form within the lst 5 yers? Yes No If "yes" type of product type of product type of product 50. Plese provide the following informtion for ech femle on this ppliction: Fmily Member.Initil menstrul cycle begun? Yes No Yes No Yes No Yes No b.dte of lst menstrul period. mm/dd/yyyy c.if (b) is more thn 35 dys go, plese explin: d.excessive or bsent menstrul bleeding? Yes No Yes No Yes No Yes No e. If (d) is yes, plese explin: Dte of lst DEPO Prover shot? mm/dd/yyyy bnorml Pp smers? Yes No Yes No Yes No Yes No Prior Cesren section or miscrrige? Yes No Yes No Yes No Yes No 51. Is ny person on this ppliction now pregnnt? Yes If "yes" Due dte / / No 52. Is ny person on this ppliction, including mle pplicnts nd dependent mles or femles, responsible for current pregnncy? If "yes" Due dte / / 53. Plese provide the following informtion for ech person on this ppliction. Within the lst five yers, hs ny person on this ppliction:. b. c. d. Hd ny medicl dvice, dignosis, cre or tretment, including prescribed medictions, recommended or received from licensed helth cre professionl, or hd ny illness, ilment, injury, helth problem, symptoms, physicl impirment, surgery or hospitl confinement not listed on pge 3? Hd chronic cough, ftigue, dirrhe, or enlrged glnds? Yes No Been dvised to hve or contemplted hving n opertion or medicl procedure not yet performed? Yes No Been scheduled to see helth cre provider t future dte? Yes No e. Tken ny prescription mediction on regulr bsis? Yes No Yes Yes No No 54. List ll medictions currently being tken by ny person on this ppliction: Medictions Prescribed by (nme/ddress/telephone number) Dte prescribed FORM 2481(Rev. 4/09) Pge 4
Section 5 (continued) - Oregon Stndrd Helth Sttement Plese provide specific detils below to ech question nswered "yes" on pges 3-4. Include insured/pplicnt's nme; the number of the question to which you nswered "yes"; the condition, tretment nd dte; the result of tretment, including ny medictions; nd the nme, ddress nd telephone number of the ttending physicin, other helth cre provider, or clinic/hospitl. Question Number Strt to end dtes HELTH HISTORY DETILS Condition ttch dditionl pges if necessry. Tretment including medictions Finl result or Plese check I hve ttched pge(s). ttending physicin/helth cre provider or hospitl (nme/ddress/telephone), ddress, nd telephone number of medicl provider(s) with current medicl record/history: Section 6 - gent Certifiction FOR GENT USE ONLY I, (the gent) certify I hve explined the eligibility provisions to the pplicnt. I hve not mde ny sttements bout benefits, conditions or limittions of the contrct except through written mteril furnished by Regence BCBSO. I hve informed the pplicnt tht the effective dte of coverge is ssigned only by Regence BCBSO, nd provided the Oregon Disclosure Informtion required. I CERTIFY THT THE INFORMTION SUPPLIED TO ME BY THE PPLICNT HS BEEN TRULY ND CCURTELY RECORDED HERE. gent (plese print or type) gent E-mil Regence BCBSO gent Number freequote@smrthelthquote.com 2398-000 gency Phone Number Fx Number SmrtHelth (503) 287-8808 (503) 287-8188 Street ddress City Stte ZIP Code 4370 NE Hlsey St. Portlnd OR 97213 gent's Signture (Required) GENT: COLLECT NO PREMIUM WITH PPLICTION Dte (Required) Pge 5
Section 7 - Certifiction, uthoriztion nd Signture Be sure to sign nd dte the ppliction below. Spouse/Domestic Prtner nd/or dependent's (ge 18-22) signture is required, if pplicble. Signture pplies to both "Certifiction of Completeness nd Correctness" nd "uthoriztion for Use nd Disclosure of Protected Helth Informtion": CERTIFICTION OF COMPLETION ND CORRECTNESS I ffirm tht the nswers given in this ppliction re true, complete, nd correct. I m providing these nswers s prt of the ppliction procedure required by Regence BCBSO to enroll in their coverge. I understnd tht Regence BCBSO will rely on ech nswer in mking coverge nd rting determintions. For the protection of ll our members, frud or misrepresenttion of mteril fct by me for the purposes of defruding Regence BCBSO my result in Regence BCBSO tking ny ction llowed by lw or contrct, including termintion or rescission of coverge, denil of benefits, nd/or pursuit of criminl chrges nd penlties. If coverge is rescinded for frud or intentionlly misleding sttements, Regence BCBSO will reimburse premium less ny clims pid nd will pursue reimbursement for clims pid exceeding ny premium. I will promptly inform Regence BCBSO in writing if nything hppens before my coverge tkes effect tht mkes this ppliction incomplete or incorrect. I understnd nd gree tht no coverge shll be in force until pproved by Regence BCBSO. Regence BCBSO my phone me to clrify nswers on this ppliction. s the pplicnt, I understnd I hve the right to inspect the informtion in my file. I further ffirm tht I received disclosure sttement nd outline of coverge from Regence BCBSO or its uthorized gent describing the individul contrct. UTHORIZTION FOR USE ND DISCLOSURE OF PROTECTED HELTH INFORMTION I cknowledge nd understnd my helth pln my request or disclose helth informtion bout me or my dependents (persons who re listed for benefits coverge on the ppliction form) from time to time for the purpose of fcilitting helth cre tretment, pyment or for the purpose of business opertions necessry to dminister helth cre benefits, or s required by lw.* Helth informtion requested or disclosed my be relted to tretment or services performed by: - physicin, dentist, phrmcist or other physicl or behviorl helth cre prctitioner; - clinic, hospitl, long-term cre or other medicl fcility; - ny other institution providing cre, tretment, consulttion, phrmceuticls or supplies, or; - n insurnce crrier or helth pln. Helth informtion requested or disclosed my include, but is not limited to: clims records, correspondence, medicl records, billing sttements, dignostic imging reports, lbortory reports, dentl records, or hospitl records (including nursing records nd progress notes). seprte uthoriztion will be required for psychotherpy notes. I understnd tht if this ppliction contins ny mteril missttements or omissions, Regence BCBSO my deny coverge, modify or cncel coverge nd/or tke ny other legl ction vilble to us by lw. * For more informtion bout such uses nd disclosures, including uses nd disclosures required by lw, or for description of gent/broker compenstion plese refer to the Regence Consumer Privcy Notice. copy is vilble on our Web site t www.or.regence.com or by telephone request t 1 (800) 365-3155. Signture of pplicnt, prent or legl gurdin if pplicnt is under 18 yers of ge or leglly incompetent * Reltionship Dte Signture of pplicnt's legl spouse or eligible domestic prtner * Signture of dependent(s) between 18 nd 22 yers of ge * Signture of dependent(s) between 18 nd 22 yers of ge * * If signture by personl representtive of the member/enrollee plese complete the following: Personl Representtive's (plese print) Reltionship to Individul Dte Dte Dte (ttch legl documenttion if other thn prent of minor child) If dditionl helth informtion is required to qulify you or fmily member for coverge, we my send you seprte uthoriztion form for the purpose of obtining medicl informtion. THIS UTHORIZTION MY NOT BE USED FOR PSYCHOTHERPY NOTES (Notes recorded nd seprtely mintined by mentl helth professionl documenting or nlyzing the contents of converstion during counseling session.) PLESE CONTINUE TO SECTION 8 Pge 6
Plese indicte one billing option: Section 8 - Premium Billing Options (if ppliction is pproved) PLESE DO NOT SEND MONEY WITH THIS PPLICTION. Monthly (checking ccount deductions - see below) Qurterly Bill (every three months) Monthly Bill SUREPY UTHORIZTION Surepy is simple nd convenient wy to keep your helth coverge in force. If you select the Surepy option of pying for your Regence BCBSO helth insurnce the pyment will be deducted utomticlly from your ccount on the 3rd business dy of the month or 15th of the month depending on your effective dte of coverge. This will provide severl dvntges to you: Your pyment will lwys be mde on time (if funds re vilble in your ccount). You won't hve to worry bout your coverge ccidentlly lpsing due to overlooked pyments. Your monthly bnk sttement will show withdrwl nottion which is your receipt of pyment. Plese py your pper bill until you re notified tht your electronic funds trnsfer hs been strted. Processing my tke up to 60 dys. GETTING STRTED is s esy s 1-2 - 3: 1. Complete, dte nd sign the uthoriztion below. 2. Write "void" on one of your checks. 3. Return this completed form nd your "voided" check (not deposit slip). SOME SUGGESTIONS: Check register reminder: When you receive your monthly sttement be sure to enter the pyment mount in your check register. This will help you keep your ccount in blnce nd void overdrft problems. If you chnge your bnk or wish to cncel your utomtic deduction. 1. Do this t lest 15 dys before your next premium is due. We suggest you leve enough money in your old bnk ccount to cover your pyments in cse there is dely in processing the chnge. 2. Just send us copy of your new "voided" check nd note explining tht you hve chnged bnks. 3. Chnges my lso be mde by clling Customer Service t 1 (800) 365-3155. SUREPY UTHORIZTION 1. COMPLETE nd sign this uthoriztion form. 2. TTCH your voided check (not deposit slip). 3. RETURN to Regence BlueCross BlueShield of Oregon (PO Box 1271, MS5K, Portlnd, OR 97201-1271). UTHORIZTION TO MY BNK Checking ccount Svings ccount s convenience nd on behlf of the ccount Holder identified below, I/we hereby request nd uthorize you to py nd chrge to the ccount identified below, checks or electronic debits drwn on the ccount by nd pyble to the order of Regence BlueCross BlueShield of Oregon, Portlnd, Oregon. I/we gree tht your rights to ech such check or electronic debit shll be the sme s if it were n ctul check drwn on you nd signed by me/us. This uthority is to remin in effect until revoked by me/us in writing, nd until you ctully receive such notice, I/we gree tht you shll be fully protected in honoring ny such check. I/we further gree tht if ny checks or electronic debits be dishonored, whether with or without cuse nd whether intentionlly or indvertently, you shll be under no libility whtsoever even though such dishonor results in forfeiture of insurnce. photocopy of this executed uthoriztion shll be s vlid s the originl. Finncil Institution Trnsit/Routing Numbers ccount Number B ccount Holder's (plese print) ccount Holder's uthorized Signture(s) - s it ppers on bnk records Dte Pge 7