Sena Health Enrollment Form

To enroll in this program, please sign this form and fill in your information. Full details can be found below.

As a member on a Bancroft Medical Plan, you are eligible for a new benefit provided by Sena Health, LLC (“Sena”), a HIPAA-protected partner of the Bancroft Health. This benefit provides Health Coordinators to assist you in effectively navigating the complex healthcare system, helping you find available medical, wellness and clinical providers, and assisting you scheduling of your services with the providers you have selected.

These services are completely voluntary, are completely free to you, and Bancroft is paying the full cost of the services.

By signing my name, I am indicating my understanding and acceptance of the eligibility criteria and authorizations as set forth below.

After enrolling, a Health Coordinator will reach out for intake from (609) 503-4707 within 48 hours.

Are you currently enrolled in a Bancroft Medical Plan or have you recently elected benefits?*

I am currently enrolled in a Bancroft Medical PlanI have recently elected my benefits and they will be effective soonI am not enrolled in a Bancroft Medical plan and have not elected any benefits

Signature*

Name*

First NameLast Name

I am a:*

Employee ID Number (if applicable)

Date of Birth*

Date

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Family members or caregivers that can give and receive my health information:

First NameLast Name

An explanation of Sena Health Services

The overarching goal of the Sena Health program is to provide you with the right services, at the right time, in the right setting, by the right providers. When you need support, Health Coordinators will work directly with you (or your authorized representative) in an effort to assist you with what you need. Available 24/7/365, these Health Coordinators will obtain and provide the information you require to enable you to make informed and educated decisions regarding your individualized care.

Eligibility Criteria

To be eligible for Sena Health services, you must sign below, indicating your agreement to the following:

I acknowledge that my use of Sena Health services is entirely voluntary and that I am free to begin or end using the services at any time, and for any reason.
I acknowledge that Sena Health’s Health Coordinators do not provide medical, wellness or clinical care, rather they assist me in identifying and selecting available medical, wellness and clinical care providers.
I acknowledge that I retain absolute autonomy and authority to control the decisions relating to my care. The services and providers I select and utilize are entirely up to me.
I acknowledge that, when requested by me to do so, the Health Coordinators will contact the providers I select and facilitate the scheduling of my services with those providers.
I acknowledge that I have the right to be informed verbally and in writing of my payment responsibilities before any services are facilitated for me by the Health Coordinators.
I acknowledge that the Sena Health “Notice of Privacy Practices” has been made available to me here and that I was given an opportunity to ask questions about those Privacy Practices.
I acknowledge that more information about Sena Health services is available at www.bancroftbenefits.com.

If you are disenrolled from your Bancroft health benefit plan for any reason, Sena Health services will stop effective the date of disenrollment. Services will occur automatically upon any future re-enrollment with a Bancroft health benefit plan.

To utilize Sena Health services, you must agree to the following authorizations by indicating your acceptance below:

I authorize Sena Health and its Health Coordinators to view and access my health
information through computerized systems called Health Information Exchanges (“HIE’s”). Note: HIE’s collect health information from the places where you have received medical treatment and make it available electronically to those you authorize. Your health information in the HIE will be used by the Health Coordinators to assist you in identifying and selecting available medical, wellness and clinical care providers.

I authorize Sena Health to use and/or disclose the health information obtained from HIE’s, and directly from me or my authorized representative, to schedule the services that I request and facilitate payment to:

any hospital, nursing home or other healthcare facility to which I may be / have been admitted;
any physician or other clinician providing me with care;
family members I authorize below, and other caregivers who are involved with my plan of care;
licensing and accrediting bodies and other health care providers in order to initiate treatment; and
any person or entity involved with administration, billing, or quality and risk management.