Orhi.us

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. Payment Options:
- 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: Individual Application
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 Subscriber
*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)
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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
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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 35. Osteoarthritis/osteoporosis/osteopenia 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:
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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) EMPLOYER CONTRIBUTION
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 client.services@cda-insurance.com 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.
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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.
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Source: http://orhi.us/shared/OR/dl/rbcbo/2012/reg.or.health.app.1212.pdf