Carrier-Non-Group Product Conversion Request Form (Page 4 of 4) in pdf

Instructions

 This form is used to change from one non‐group product to another non‐group product. You must complete all sections and sign

and date this form and any additional pages you may need to submit with it to provide further requested information.

 Please PRINT except when a signature is requested.

 You can obtain the providers’ correct names and addresses from the appropriate provider directory. You may also obtain each

provider’s NPI number [from the provider directory] [or] [and] [at: URL] [or] [and] [by contacting the provider directly.] Providers

with multiple office locations and individual providers who belong to more than one practice or provider entity may have more than

one NPI number. You should confirm the correct NPI number for the specific provider and office location where you will be seen by

contacting that office directly.

 For provider addresses, include the zip code plus the four digit extension (11 digits)

 IF YOU HAVE ANY QUESTIONS concerning the benefits and services provided by or excluded under this [policy], contact a [member

services] representative at [phone number] before signing this form.

KEEP A COPY OF THIS COMPLETED APPLICATION! [A copy of this application may be used as a temporary ID card for 30 days from the

effective date if authorized by [Carrier Name]. Coverage must be verified with [Carrier Name] prior to visiting with a specialist or

admission to a hospital.]

Eligibility

A. Eligibility requirements are set forth under the Individual Health Coverage Reform Act of 1992, P.L. 1992, c. 161 (N.J.S.A. 17B:27A‐2 et

seq.).

B. You MUST be a New Jersey resident.

C. You must not have other health coverage besides the individual plan you currently wish to replace. “Other Health Coverage”

includes coverage under a: group health plan resulting from employment, whether with a private or public (governmental) employer,

including such coverage continued through a COBRA election or state continuation provisions; a church plan, Medicare, or another

individual health benefits plan

On behalf of myself and the dependents listed in this Non‐Group Product Conversion Request form, I acknowledge that:

1. I authorize any physician or medical professional, hospital, clinic or other medical care institution, carrier, consumer reporting

agency, and any employer to give [Carrier Name], or any consumer reporting agency acting on behalf of [Carrier Name],

information pertaining to employment, other health coverage, and medical advice, treatment or supplies for any physical or

mental condition relevant to me or a minor dependent applying for coverage. I agree that this authorization shall be valid for 30

months from the date I sign this form, unless revoked at an earlier date.

2. I agree that, if I revoke this authorization before it expires, such revocation shall not affect any action that [Carrier Name] has

taken in reliance on the authorization.

3. I understand I may receive a copy of this authorization if I request one.

4. I agree [Carrier] will provide coverage in accordance with the terms of the contract for the individual [plan] [policy].

5. I understand that my enrollment and the enrollment of my listed dependents in [Carrier’s Name’s] individual [plan] [policy] is

conditioned upon acceptance by [Carrier’s Name].

I agree that the provision of coverage and benefits is contingent upon payment of premiums and may be terminated in accordance

with the terms of the individual [plan] [policy] if premiums are not paid timely.

Misrepresentations: Any person who includes any false or misleading information on a Non‐Group Product Conversion Request Form

for a health benefits plan is subject to criminal and civil penalties.

Carrier-Non-Group Product Conversion Request Form Page 4