I hereby apply for this coverage through AultCare Health Insurance Company. I further agree to participate in and agree to be bound to the relevant terms of the Master Group Policy and my Certificate of Insurance.
All information in this application, to the best of my knowledge, is complete, true and accurate. I give my consent to AultCare or its affiliated companies or authorized designees ("AultCare") to request from any provider of medical, dental or pharmacy services, any insurance company or organization, to release medical records, billing records, or any information requested with regard to any claim and/or expense reported regarding my condition or that of my family members to be covered.
I consent to allow AultCare to use and disclose my protected health information and the protected health information of my family members to be covered to any other insurance company or health plan, any state or federal agency providing health care benefits, and other persons or organizations that perform professional, business, or insurance functions for AultCare such as independent claims examiners or group plan administrators or reinsurers.
I understand that this information may be used for purposes that include but are not limited to: processing my application for enrollment; individual risk classification; detecting or preventing fraud; internal and external audits; administration of claims; case management; quality improvement programs, reviews, and audits; public health reporting: peer review; utilization review; coordination of benefits; subrogation; health promotion, disease management and prevention, and any other managed care and prevention program.
I authorize AultCare to use and disclose my protected health information and the protected health information of my family members to be covered, including but not limited to information from and concerning: mental health records; substance abuse records; reproductive health; information relating to HIV virus or AIDS; sexually transmitted or other communicable disease. I give this authorization on behalf of any eligible children and myself if covered by the plan. I am acting as their agent and representative. The consent/authorization expires in 30 months.
Authorizations signed for the purpose of collecting information with this application for an insurance policy, a policy reinstatement or a request for a change in policy benefits shall remain valid for thirty (30) months from the date this application is signed. Authorizations signed for the purpose of collecting information in connection with a claim for benefits shall remain valid for the term of this coverage or for so long as allowed by law.
I understand that I am entitled to receive a copy of this authorization upon request and a photocopy is as valid as the original.
INSURANCE FRAUD WARNING: Any person who, with intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Eligible and Ineligible Employees
I have read all of the statements contained in this application and declare by signing this application the information I have provided is true and complete to the best of my knowledge. Signature of Spouse authorizes release of information described previously on this application.