Questions? Call CDA Insurance: 1-800-884-2343 or 541-434-9613 Regence Application Tips for completing the application:
1. Please read everything carefully and answer all questions honestly. This document becomes
2. Please complete all sections to the best of your ability. Please pay special attention to the
health history section. By including the specific details to questions you answered 'yes" to, the processing of your application will be expedited. Be sure to include:
a. The specific name and date of the diagnosis or condition and correct spelling. b. The treatment(s) that were done, including the last time you visited the doctor for this
condition and medications that were prescribed and medications that are currently being taken.
c. Final result refers to the status of the condition. If it has been treated and your doctor
has not requested any follow-ups, please state so. If you are still seeing the doctor, please state so.
d. Complete name, address and phone number of the doctor.
Prior Insurance? Yes:
Please refer tofor more information. Please note, if you do not have your Certificate of Creditable Coverage at the time of application, please submit your application anyway. Credit for pre-existing condition waiting periods will be credited upon receipt of your Certificate of Creditable Coverage by Regence BlueCross BlueShield of OR.
If your application is approved, when the policy is sent to you, there will be a form that will need to be signed and returned to us stating that you understand there is a 6 month waiting period on pre-existing conditions before you will be covered for conditions that you been diagnosed with or seen a doctor for before the policy is effective.
- Monthly Bank Draft: Please complete Authorization section carefully and attach a voided
- Direct Bill: Simply check the Direct bill , and you are done
Final check list before mailing:
- All sections completed? - Copy of Insurance Card or Certificate of Credible Coverage - Signed and Dated - Voided check if selecting the automated monthly withdrawal
Send Completed Application to: CDA Insurance LLC PO Box 26540 Eugene, Oregon 97402
Tol -free FAX: 1.888.632.5470 or 541.284.2994 Email:
Please read carefully and make sure all sections of the application are answered completely. Use ink to complete, sign and
date the application to avoid having it returned to you. SECTION 1 - ELIGIBLE TO APPLY FOR COVERAGE? 1. If you are currently eligible for Medicare, or wil be on the requested effective date of coverage for which you are
applying, you are not eligible for private individual or family health coverage and should not fil out this application.
2. You must be a permanent Oregon resident. A photocopy of a valid Oregon state driver's license, identification card,
or similar proof of residency acceptable to Regence BlueCross BlueShield of Oregon (Regence) may be requested.
For more information please contact your producer or call our Sales department toll-free at 1-888-REGENCE
(1-888-734-3623). SECTION 2 - EFFECTIVE DATE Your application is subject to review and approval by Regence. Complete applications received in our office by 5:00 PM
Pacific Time on the last business day of the month wil be eligible for an effective date of the first of the following month,
unless otherwise indicated. Incomplete applications may receive a later effective date. Requested Effective Date SECTION 3 - TYPE OF APPLICATION (check one) New enrollment (applying to become a new Regence member) Addition of a spouse/domestic partner and/or child to my existing policy Change to existing individual plan or deductible (existing Regence member applying to change benefit plans) Note: Your policy must be paid current in order for a plan change to be made. If your policy cancels due to non-payment,
you wil need to reapply by submitting a new Individual Application. SECTION 4 - ENROLLMENT INFORMATION List all eligible family members to be covered. Eligible family members include a spouse/domestic partner, and/or any
child who is under age 26 or who is medically certified as disabled. Copy of certification required.
First Name, MI Relationship to Gender Age Height Weight Birthdate
*Non-Certified Domestic Partners must submit an Affidavit of Domestic Partnership
OO1212IIMA SECTION 5 - ADDRESS AND PHONE NUMBER
Mailing Address (if different than residence street address)
E-Mail Address (wil not be disclosed outside of the company)
SECTION 6 - MEMBER CARD (check one) Family Level Card (all members listed on the same card) Member Level Card (each member on a separate card) SECTION 7 - PLAN SELECTION (Detailed benefit information can be found online at regence.com) MEDICAL PLANS (check one): Evolve Core
Deductibles are per member (family deductible is three times the individual amount)
Evolve HSA Evolve HSA 100 NETWORK OPTIONS: Applicants who reside in the Portland Metropolitan Area (Clackamas, Multnomah, Washington, and Yamhill Counties) must select one of the following Network Options. (Anyone outside the Portland Metropolitan Area will remain on the PPO network) DENTAL OPTIONS (check one) No Dental Dental Option 1 - 100/80/50; $750 annual maximum benefit that may increase over time to $1,500 Dental Option 2 - 100% of first $200 and 50% of next $1,100 ($750 annual maximum benefit) OO1212IIMA SECTION 8 - OTHER COVERAGE INFORMATION 1. Do you or any family members have other active health or medical coverage?
If yes, do you intend to replace your current plan with this contract?
2. Do you or any family members work for an employer who offers health benefits to employees?
3. Are you currently enrolled in an Regence Individual medical plan and wish to cancel that coverage?
If you answered yes, please sign the statement below: I wish to terminate my current individual medical coverage from Regence on the effective date of this new individual
Regence Individual Plans contain a 6-month pre-existing condition limitation period. The pre-existing waiting period may
not apply to any members under the age of 19. Please provide the following information for all applicants, and attach a
copy of your Certificate of Coverage from your current or prior carrier or a similar document showing the beginning and
ending dates of your current coverage, if applicable. If current coverage is stil active, the Certificate of Coverage can be
Insurance (First, Last) Dates of Coverage Coverage OO1212IIMA SECTION 9 - OREGON STANDARD HEALTH STATEMENT Notice to Applicant: You are not required to disclose any information on any part of this application about genetic testing
or genetic information relating to you or to any blood relative. You are not required to disclose any decision by an
insurance company that is based on a genetic test or on genetic information. Regence may review its claims history for the last five years for anyone who has had insurance with Regence during that
time. List the names and Regence identification numbers of anyone on this application who has had insurance with
Has any insurance company, within the last five years declined, postponed, refused, restricted or increased
premium for health reasons for life or health insurance coverage for anyone who is listed on this
If "yes", indicate name of person affected, reason for action, and name of insurance company
Please mark "Yes" or "No" for each item (for you and any family members.) Provide details on Page 6 to any questions
answered "Yes." (For the purpose of these questions, chronic means persistent, continuous, periodic, or a combination of any of these terms.) Within the last five years, has anyone listed on this application had any medical advice, diagnosis, care, or treatment,
including prescribed medications, recommended or received from a licensed health care professional; or had any il ness,
ailment, injury, health problem, symptoms, physical impairment, surgery or hospital confinement related to any of the
26. High cholesterol (if "Yes", record last reading
27. High blood pressure (if "Yes", record last
31. Lupus, chronic muscle pain, muscle injury
32a. Mental/emotional condition/depression
32b. Therapy/counseling within last 5 years
(if "Yes", record date of last session
33. Neurological condition/disease/injury
37. Reproductive system disorder/infertility
18. Eating disorders such as, but not limited to,
19. Emphysema/asthma/chronic lung disease
41. Skin condition, abnormal or cancerous moles
21. Disease or injury of eye/cataract/glaucoma
47. Weight fluctuation (+/-20 lbs.)48. Cosmetic surgery/implants, use of
OO1212IIMA SECTION 9 - OREGON STANDARD HEALTH STATEMENT (continued)
49. Has any person on this application used tobacco products in any form within the last 5 years?
If "yes" Name
50. Please provide the following information for each female on this application:
Family Member Name(s):
51. Is any person on this application now pregnant?
If "yes" Name
52. Is any person on this application, including male applicants and dependent males or females,
If "yes" Name
53. Please provide the following information for each person on this application. Within the last five
years, has any person on this application:a. Had any medical advice, diagnosis, care or treatment, including prescribed medications,
recommended or received from a licensed health care professional, or had any il ness, ailment,
injury, health problem, symptoms, physical impairment, surgery or hospital confinement not listed
b. Had chronic cough, fatigue, diarrhea, or enlarged glands?
c. Been advised to have or contemplated having an operation or medical procedure not
d. Been scheduled to see a health care provider?
e. Taken any prescription medication on a regular basis?
OO1212IIMA SECTION 9 - OREGON STANDARD HEALTH STATEMENT (continued) 54. List all medications currently being taken by any person on this application: Please provide specific details below to each question answered "yes" on pages 4 & 5. Include insured/applicant's
name; the number of the question to which you answered "yes"; the condition, treatment and date; the result of treatment,
including any medications; and the name, address and telephone number of the attending physician, other health care
HEALTH HISTORY DETAILS
Attach additional pages if necessary. I have attached ________ page(s). Name, address, and telephone number of medical provider(s) with current medical record/history: OO1212IIMA SECTION 10 - PREMIUM BILLING OPTIONS (if application is approved) BILLING ADDRESS (Complete only if bil ing should be sent to an address other than the Residence Street or Mailing
Address listed in Section 5 of the application.)Name (First, Last)
No Is your employer reimbursing or paying for any portion of this policy's premium? Individual benefit plans are
not intended for sale as an employer-sponsored health benefit plan for employees. PAYMENT OPTIONS (check one): If no payment option is checked, your policy wil automatically default to Monthly Bil ing.
Surepay (premium is automatically deducted from your bank account on the 5th of each month).
If selecting the Surepay option:
1. Complete the following Authorization To My Bank section.
2. Write 'void' on one of your checks and return your voided check with this application (not a deposit slip). For savings account, please provide proof of ownership of the account. AUTHORIZATION TO MY BANK
As a convenience and on behalf of the Account Holder identified below, I/we hereby request and authorize you to pay and
charge to the account identified below, checks or electronic debits drawn on the account by and payable to the order of
Regence BlueCross BlueShield of Oregon, Portland, Oregon. I/we agree that your rights to each such check or electronic
debit shal be the same as if it were an actual check drawn on you and signed by me/us. This authority is to remain in
effect until revoked by me/us in writing, and until you actual y receive such notice, I/we agree that you shal be fully
protected in honoring any such check. I/we further agree that if any checks or electronic debits be dishonored, whether with
or without cause and whether intentionally or inadvertently, you shal be under no liability whatsoever even though such
dishonor results in forfeiture of insurance. A photocopy of this executed authorization shal be as valid as the original. Financial Institution or Bank Name Transit/Routing Numbers Account Number Check One:
Account Holder's Signature (as it appears on bank records)
SECTION 11 - PRODUCER CERTIFICATION If you have a producer, that producer may receive bonuses, commissions, administrative service fees, or other
compensation, including non-cash compensation, from Regence. Incentives may be based on any of several factors,
including the products you buy, your producer's volume of business with Regence, and the other services your producer
provides you. These incentives may have an indirect impact on your rates. For more information, please contact your
FOR PRODUCER USE ONLY
I, (the producer) certify I have explained the eligibility provisions to the applicant. I have not made any statements about
benefits, conditions or limitations of the contract except through written material furnished by Regence. I have informed the
applicant that the effective date of coverage is assigned only by Regence and provided the Oregon Disclosure Information
required. I CERTIFY THAT THE INFORMATION SUPPLIED TO ME BY THE APPLICANT HAS BEEN TRULY AND ACCURATELY RECORDED HERE. Producer Name (please print or type)
PO Box 26540, Eugene, OR 97402 firstname.lastname@example.org
OO1212IIMA SECTION 12 - CONSENT TO ELECTRONIC DISTRIBUTION Regence is engaged in efforts to increase the use of technology and curb the use of paper. In support of those efforts,
Regence has established a process under which communications to members can be posted to a secured account that a
member establishes on myRegence.com, with e-mail notice provided to a member-supplied e-mail account when a new
communication is posted. By my signature and unless I have expressly rejected electronic distribution by marking the checkbox below, I consent, on
behalf of myself and any covered dependents, to the electronic distribution of communications related to the coverage
To access electronically distributed communications, I and each of my covered dependents wil need to establish
A myRegence.com accounts for use on a system meeting the outlined requirements and I represent that we each have
and wil continue to have access to such a system or systems. Not all member communications are currently available electronically, but agree that my consent wil apply to the
A following materials available, or as they become available, for electronic distribution, (i) notices of enrollment and/or
effective date, (ii) acknowledgements of receipt of claims, requests for additional information related to claims and
notices of associated delays in processing, and determinations on submitted claims, (ii ) general informational
disclosures required by law, including but not limited to notices of rights under the Women's Health and Cancer Rights
Act, state patient protection acts, and privacy laws, (iv) communications regarding complaints, grievances, or appeals,
including but not limited to acknowledgements of receipt, requests for additional information and notices of associated
delays, and notices of determinations, (v) summaries of benefits and coverage and uniform glossary of terms, (vi)
notices of benefit changes or policy modifications, (vi ) renewal information, (vi i) notices of discontinuation, (ix) notices
of termination and continuation coverage rights, (x) certificates of creditable coverage, (xi) bil ing notices and
Until a type of communication can be distributed electronically, a paper copy wil be provided.
A Once available in electronic form, any electronically distributed communications may be printed from the
A myRegence.com account where they are posted, or a paper copy of any particular communication may be requested at
any time using myRegence.com or by contacting Regence Customer Service at the number provided on my ID card. I may change the e-mail address for receipt of notice of electronic distributions or withdraw consent (returning to paper
A distribution) at any time and without charge using myRegence.com or by contacting Regence Customer Service as
The e-mail address for receipt of notice of electronic distributions is
I do not want electronic distribution. Unless my consent is not required for an electronic distribution, I elect to receive
communications related to this coverage in a paper format. OO1212IIMA SECTION 13 - CERTIFICATION, AUTHORIZATION AND SIGNATURE Be sure to sign and date this application. Spouse/Domestic Partner and/or child's (age 18-25) signature is required, if
applicable. Signature applies to both "Certification of Completion and Correctness" and "Authorization for Use and
Disclosure of Protected Health Information". Certification of Completion and Correctness I affirm that the answers given in this application are complete and correct. I have provided these answers as part of
the application procedure required by Regence to enroll in its insurance coverage. I understand that if this application
contains any intentional misrepresentations of material fact, Regence may, within the first two years of coverage, deny
coverage, modify or cancel the contract, or take other legal action. I further understand that if the misrepresentation
amounts to fraud, Regence may deny coverage, modify or cancel the contract, or take other legal action even after the
first two years of coverage. I wil promptly inform Regence in writing if anything happens before my coverage takes effect
that makes the information I have provided on this application incomplete or incorrect. I understand and agree that no
coverage shal be in force until approved by Regence. If approved, coverage wil be in force as of the effective date
determined by Regence. Regence may contact me to clarify answers on this application. As the applicant, I understand I
have the right to inspect the information in my file. I further affirm that I received a disclosure statement from Regence or
Authorization for Use and Disclosure of Protected Health Information
I acknowledge and understand my health plan may request or disclose health information about me or my dependents
(persons who are listed for benefits coverage on the application form) from time to time for the purpose of facilitating
health care treatment, payment or for the purpose of business operations necessary to administer health care benefits, or
as required by law. Health information requested or disclosed may be related to treatment or services performed by:
a physician, dentist, pharmacist or other physical or behavioral health care practitioner;
A a clinic, hospital, long-term care or other medical facility;
A any other institution providing care, treatment, consultation, pharmaceuticals or supplies, or;
A an insurance carrier or health plan.
Aalth information requested or disclosed may include, but is not limited to: claims records, correspondence, medical
records, bil ing statements, diagnostic imaging reports, laboratory reports, dental records, or hospital records (including
nursing records and progress notes). This authorization may not be used for psychotherapy notes (notes recorded
and separately maintained by a mental health professional documenting or analyzing the contents of a conversation during
a counseling session). A separate authorization wil be required. * For more information about such uses and disclosures, including uses and disclosures required by law, please refer to the
Regence Consumer Privacy Notice. A copy is available on our Web site at regence.com or by telephone request at 1 (800) 365-3155. SIGNATURES
Signature of applicant, parent or legal guardian if applicant is under 18 years Relationship
X Signature of applicant's legal spouse or eligible domestic partner * X Signature of child between 18 and 25 years of age * X Signature of child between 18 and 25 years of age * * If signature by a personal representative of the member/enrollee please complete the following: Personal Representative's Name (please print)
If additional health information is required to qualify you or a family member for coverage, we may send you a separate
authorization form for the purpose of obtaining medical information. OO1212IIMA
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