"I hereby represent that I am an employee of the participating employer and that the statements and answers to the questions on this enrollment form are true and complete to the best of my knowledge and belief. I understand that the statements and answers contained herein will be used by Exemplar Insurance Associates ("EIA") to determine eligibility for coverage under the Self-Funded Program ("Program") for myself and persons listed on this enrollment form as my spouse and/or dependent children.
I understand and acknowledge that I have elected to participate in the Section 125 plan offered by my employer, and I agree that my qualified insurance premiums may be paid by my employer through pre-tax salary/earnings reductions. I further acknowledge that my Social Security contribution and subsequent Social Security benefit will be slightly reduced."
"I understand that (1) the answers given will be the basis of any coverage provided; (2) any material misrepresentation or failure to provide complete information to questions on this enrollment form may be used as a basis for changing rates or terminating coverage; (3) if coverage is not approved, I, my spouse and/or dependent children are not entitled to benefits; (4) if I, my spouse and/or dependent children waive coverage and decide to apply for coverage at a later date, evidence of eligibility may be required and benefits may be deferred for a specified period of time; and (5) coverage will not be effective until my employer receives notice that this enrollment form has been approved by EIA.
I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically-related facility, insurance company, pharmacy or pharmacy-related entity, pharmacy benefits manager (PBM) or PBM-related entity, insurance or reinsurance company or employer, having information about me or my minor children to provide all such information as may be requested to EIA, its legal representative or any medical records retrieval service EIA may engage."
"This authorization includes any and all information any of the foregoing may have about me, including, but not limited to, information regarding diagnosis, testing, treatment and prognosis of my physical or mental condition as well as alcohol abuse treatment, drug abuse treatment, psychiatric treatment, pharmacy prescriptions, HIV testing and treatment, STD testing and treatment, sickle cell testing and treatment, lab data and EKGs. This information may also be disclosed to any medical records company engaged by EIA. Although federal regulation requires that we inform you of the potential that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by such regulation, all information received by EIA pursuant to this authorization will be protected by federal and state privacy laws and regulations."
"I understand and agree that in connection with my application for coverage under the Program: (1) EIA may obtain consumer reports which may include credit information, a driver history report, and/or personal or privileged information from third parties; (2) such information may be disclosed to affiliated or unaffiliated third parties without my prior permission but only as permitted or requiredbylaw; (3) upon my written request, EIA will inform me if a consumer report was requested and the name and address of the consumer reporting agency that furnished the report; (4) I may also request access to and correction of information EIA has collected on me; (5) EIA may request and use subsequent consumer reports in updating and renewing any insurance afforded in connection with this Application; and (6) EIA will furnish a more detailed explanation of its information practices upon my request."
"In connection with this application for insurance, EIA will review my credit report or obtain or use an insurance credit score based on the information contained in that credit report. EIA may use a third party in connection with the development of my insurance credit score. I may request that my credit information be updated and if I question the accuracy of the credit information, EIA will, upon my request, reevaluate me based on corrected credit information from a consumer reporting agency."
"I hereby authorize EIA to obtain consumer reports on me."
"I understand that this authorization is required in order to enable EIA to make eligibility or enrollment determinations relating to me, my spouse and/or my dependents or for EIA to make underwriting or risk rating determinations. If I refuse to sign or revoke this authorization, or refuse to authorize EIA to obtain a consumer report on me, EIA may refuse to consider my application for enrollment."
"I understand that I may revoke this authorization at any time by notifying EIA in writing of my desire to revoke. Such revocation must be sent by certified mail to the following address: Exemplar Health, 1107 West Market Center Drive, High Point, NC 27260. Such revocation will not be valid to the extent EIA has taken action in reliance on the authorization prior to its revocation. This authorization expires upon the earliest of the following: denial of my application, declination of enrollment, or when I am no longer covered under the Program, but in no event will this authorization be in effect for longer than 24 months from the date signed."
"I acknowledge that knowing and willful misstatements in this enrollment form may constitute health care fraud, a criminal violation of 18 ection 1347 (punishable by up to 10 years in prison)."