In the event that information submitted on this form constitutes fraud or there is an intentional misrepresentation of the material fact, the plan may rescind coverage, for either the individual or the entire group. In any such case, I understand that the plan will return any contributions that have previously been paid as to the rescinded coverage. I certify that the statements are true and correct to the best of my knowledge. I understand that this form is used for information only and does not bind coverage. Triad gathers this information for statistical and actuarial use only. This information is not to be used in connection with any decisions or actions regarding any individualâs employment. Prospective employees in Michigan should not provide information regarding height or weight. In compliance with requirements for GINA, Conquer is not requesting genetic information. Triad Program Notice of Privacy Practices provides more detailed information about how the program and the health plan I have chosen may use and disclose my protected health information. I have a legal right to review this Notice of Privacy practices before I sign this consent and I am encouraged to read it in full. I have a right to request restrictions on how my protected health information is used and disclosed. The Triad Program and my health plan are not required by law to grant my request. However, if my request is granted, the Triad Program and my health plan are bound by their agreement. I have a right to revoke this consent in writing, except to the extent the Triad Program or my health plan have already used or disclosed my protected health information in reliance upon my consent. I will notify Triad of any health or enrollment related changes that occur after signing this form up to the effective date of coverage on the health plan. By signing this PHQ, I acknowledge that I will automatically become a passive, non-voting certificate class member of Triad Benefits, LLC. This certificate of membership will remain in force for a long as I continue to participate in benefits offered through Triad Benefits, LLC. I further understand that while I have a certificate membership in Triad Benefits, LLC., that affords me no managerial status, voting rights or rights to profits or liabilities. I grant full managerial duties to the duly appointed managers of Triad Benefits, LLC., a manager-managed LLC. Additionally, by becoming a Certificate Member, I acknowledge that I will only have access to consulting services and products specifically designed for Triad Benefits, LLC. members. Member understands and agrees the Plan may modify health care fees or be terminated based on Member's experience and/or utilization. Any such modification or termination must be presented to the member 45 days prior to the members renewal date. Client Privacy Notification Thank you for completing the requested information above. Any non-public personal health information (i.e., name with address and/or social security number and detailed health information)(protected health information) that you provide via hard copy or through this process will be used solely for the purpose of providing a risk assessment to Triad Benefits to provide a health care benefit quote. Triad Benefits actuary and underwriter are acting as a Business Associate and are subject to certain provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. Triad Benefits actuary and underwriter will not sell, license, transmit or disclose this information outside of their offices except as: a)necessary for them to provide the services on behalf of the plan, b) expressly authorized by you, c) necessary for backup documentation purposes, or d) required by law