Fillable Employee Enrollment Form (Page 5 of 6) in pdf

Subscriber Last, First Name ______________________________________________

SSN____________________________________________

G. Authorization to Release Medical Information and Signature

I authorize UnitedHealthcare Insurance Company and its affiliates (“UnitedHealthcare and Affiliates”) to obtain, use and disclose my medical, claim or

benefit records, including any individually identifiable health information contained in these records. 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, who may be in possession of my confidential health information, to disclose my information to UnitedHealthcare and Affiliates. I

understand this authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my ability to enroll in the health

plan or receive benefits, if permitted by law. I understand I may revoke this authorization at any time by notifying my UnitedHealthcare and Affiliates

representative in writing, except to the extent that action has already been taken in reliance on this authorization. As required by HIPAA, UnitedHealthcare

and Affiliates also request 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 (with the exception of HIV/AIDS health information) and no longer protected by federal privacy regulations except as prohibited by state

law. This authorization, unless revoked earlier, expires 30 months after the date it is signed.

I understand that I am completing a health application and that each response must be complete and accurate. I (we) request the indicated group medical

coverage for myself and, if the plan provides, for my dependents. I authorize any required premium contributions to be deducted from earnings. I (we) have

not given the agent or any other persons any health information not included on the Request for Coverage. I (we) understand that the HMO/insurance

company(ies) 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

Request for Coverage and any attachments. UnitedHealthcare is only seeking to collect information about the current health status of those persons listed

on the application. You should not include any genetic information. Please do not include any family medical history information related to genetic services

or genetic diseases for which you believe you or your dependents may be at risk.

Please maintain a copy of this authorization for your records.

Employee Signature

Employee Name (please print)

Date

_______/________/_______

H. Binding Arbitration

I AGREE AND UNDERSTAND THAT ANY AND ALL DISPUTES, INCLUDING CLAIMS RELATING TO THE DELIVERY OF

SERVICES UNDER THE PLAN AND CLAIMS OF MEDICAL MALPRACTICE (THAT IS, AS TO WHETHER ANY MEDICAL

SERVICES RENDERED UNDER THE HEALTH PLAN WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY,

NEGLIGENTLY OR INCOMPETENTLY RENDERED), EXCEPT FOR CLAIMS SUBJECT TO ERISA, BETWEEN MYSELF AND MY

DEPENDENTS ENROLLED IN THE PLAN (INCLUDING ANY HEIRS OR ASSIGNS) AND UNITEDHEALTHCARE OF CALIFORNIA,

UNITEDHEALTHCARE OR ANY OF ITS PARENTS, SUBSIDIARIES OR AFFILIATES, SHALL BE DETERMINED BY SUBMISSION

TO BINDING ARBITRATION. ANY SUCH DISPUTE WILL NOT BE RESOLVED BY A LAWSUIT OR RESORT TO COURT PROCESS,

EXCEPT AS THE FEDERAL ARBITRATION ACT PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. ALL

PARTIES TO THIS AGREEMENT ARE GIVING UP THEIR CONSTITUTIONAL RIGHTS TO HAVE ANY SUCH DISPUTE DECIDED IN A

COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF BINDING ARBITRATION.

Employee Signature (Required)

Employee Name (please print)

(Required)

Date (Required)

_______/________/_______

I. Census Information

NOTE: Data collected in this section will be used only to help communicate with enrollees and inform them of specific programs to enhance their well-

being. This information will not be used in the eligibility process.

Race, check all that apply:

White

Black, African-American

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Asian

Hispanic/Latino

Other Race, please specify_______________________

Health plan coverage provided by or through UnitedHealthcare Insurance Company and UnitedHealthcare of California. Administrative services provided by United Healthcare

Services, Inc., OptumRx, Inc or OptumHealth Care Solutions, Inc. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC) or United Behavioral

Health (UBH). Dental coverage provided by UnitedHealthcare Insurance Company and Dental Benefit Providers of California, Inc. Vision coverage provided by UnitedHealthcare

Insurance Company.

CALIFORNIA LAW PROHIBITS AN HIV TEST FROM BEING REQUIRED OR USED BY HEALTH CARE SERVICE PLANS AND

INSURANCE COMPANIES AS A CONDITION OF OBTAINING COVERAGE.

LG.EE.12.CA 9/12

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