Benefits Enrolment

Personal enrollment information

I certify to all of the following on behalf of myself and the persons listed on this application as eligible dependents: (1) I have read this entire form; (2) I understand and agree to its terms; (3) I apply for enrollment of group benefits as indicated on this form, subject to all terms and conditions of the coverage, as offered by the Trust.
I authorize BlueCross BlueShield Arizona and affiliates to obtain, use and disclose my medical, claim or benefit records, including any individually identifiable health information contained in these records. Dental coverage provided by MetLife. I understand these records may contain information created by other persons or entities (including health care providers) as well as information regarding the use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes), sexually transmitted disease and reproductive health services. I authorize any health care provider, pharmacy benefit manager, other insurer or reinsurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to disclose my information to BlueCross BlueShield Arizona and Affiliates. I understand that the purpose of the disclosure and use of my information is to allow BlueCross BlueShield Arizona to facilitate the appropriate management of treatment, services, payment and benefits. I further understand that the information disclosed will not be used for purposes of eligibility, enrollment, underwriting and premium risk rating. I understand this authorization is voluntary and I may refuse to sign the authorization. I understand I may revoke this authorization at any time by notifying my BlueCross BlueShield Arizona representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, BlueCross BlueShield Arizona also requires that I acknowledge the following, which I do: I understand that information I authorize a person or entity to obtain and use may be re-disclosed and no longer protected by federal privacy regulations. This authorization, unless revoked earlier, expires 30 months after the date it is signed. I (we) have not given the agent or any other persons any required information not included on the application. I (we) understand that BlueCross BlueShield Arizona is not bound by any statements I (we) have made to any agent or to any other persons, if those statements are not written or printed on this application and any attachments. Please note that if you leave out information or make a misrepresentation on this form we may be allowed by law to take one or more of the following actions: terminate or non-renew your coverage or change your premium retroactively to the date your policy became effective. Please maintain a copy of this authorization for your records.
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