• I understand:

  • It is my responsibility to confirm that my current medications are on your plan's drug list.
  • It is my responsibility to review the Summary of Benefits for the plan I have selected.
  • There is limited coverage for foreign travel under my policy.
  • I should not cancel any existing health insurance coverage until your policy is approved.
  • It is my responsibility to cancel my prior health insurance coverage. A company will not "back date" a cancellation request so I must make steps to make sure my policy was cancelled, even if a representative of ISC assisted you with the cancellation. ISC wil NOT be notified of the cancellation of your policy.
  • ISC will not discuss your policies with anyone unless requested by you in writing.

   

  Health/Advantage Plans Only:

  • My plan has a Provider Network and it is my responsibility to verify that my doctor(s) and/or facilities are in my network.
  • I need to pre-certify for surgery (including some outpatient procedures), hospitalization, and durable medical equipment.

   

  I/we understand the items above.

Optional Spousal Authorization:

I authorize Insurance Service Center - DePere, LLC (ISC) and its staff/agents to release my personal health information on specific treatment or services I have received. These records may have information created by others. The Health Insurance Portability and Accountability Act (HIPAA) requires us to get your permission before we release your information.

I understand that I may end this authorization at any time. I must do so in writing. I must send my written request to ISC. If ISC has already released any of my personal health information before it receives my written request, my request will not cancel out any requests for information made prior to receiving the written request. This permission is voluntary. I may refuse to sign this form. If I refuse, it will not affect my health benefits. Once health information about me has been given out, it could be redisclosed and it may not be protected by federal privacy laws.