I hereby apply for myself and my eligible family members for the coverage specified in the Contract between my
Group/Employer and Anthem BlueCross and BlueShield of Georgia, Kaiser Foundation Health Plan of Georgia HMO,
Aetna Health Dental PPO or HMO, or EyeMed Vision (hereinafter referred to as the Plans).
I understand and agree that the effective date of coverage will be governed by the stipulations of the Group Application
and the Master Group Contract under which this application is made. I understand that membership will continue
according to the terms of the contract between the employer and the Plans. I hereby authorize the employer to
periodically deduct any charge due from me hereunder and to remit same to the Plans along with any contribution due
from the employer.
I hereby authorize any hospital, physician, psychiatrist, psychologist, counselor, psychiatric hospital or other provider,
dispenser of prescription drugs, appliances, ambulance service or any person or any institution rendering services to me
or members of my family, if covered hereunder, to furnish the Plans all requested information concerning treatment,
advice, psychiatric care or medical care for previous or future conditions, illnesses or disabilities.
I declare that all statements made hereon including the information provided on the front of this application are complete
and true to the best of my knowledge and belief, and agree that the Plans may cancel this coverage within two (2) years
from the effective date, for any ineligible family member or one on whom erroneous or false information has been
submitted, personally assuming liability for reimbursement to the Plans for any benefit payment made on behalf of such
family member. After this contract has been in force for a period of two (2) years during the lifetime of the insured, it shall
become incontestable as to the statements in the applications. I understand that I am responsible for giving notice to my
Group/Employer of any changes in my status and that of my family members that affect coverage.
ABBREVIATED NOTICE OF INSURANCE INFORMATION PRACTICES
PRIVACY ACT. Georgia state law establishes standards for the collection, use and disclosure of information gathered in
connection with insurance transactions. The application attached to this notice contains specific personal questions about
you and your dependents. Your answers are required to determine if you qualify for coverage. Plans are required to
advise you that personal information may be collected from persons other than you or other individuals proposed for
coverage. An investigative consumer report may be made to help obtain additional medical data from physicians or
hospitals.
ALL DATA IS CONFIDENTIAL. Plans are required by law to keep such data confidential. It will be seen only by their
employees and authorized agents. This data may in certain circumstances be disclosed without your authorization. Plans
may furnish such data to authorized federal or state agencies, consumer investigative service bureaus or others if part of
standard business practice or required by law.
ACCESS TO YOUR DATA. You have the right to see or obtain a photocopy of your personal information. You also have
the right to send a written request if you want any of your personal information to be amended, corrected or deleted. If you
wish to have a more detailed explanation of information practices, please contact the applicable carrier:
•
Anthem BlueCross and BlueShield of Georgia, Customer Service Department, Post Office Box 7368, Columbus,
Georgia 31908–7368
•
Aetna, Inc., RT-52, 151 Farmington Avenue, Hartford, Connecticut 06156
•
Kaiser Foundation Health Plan of Georgia, Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305
•
EyeMed Vision Care, 4000 Luxottica Place, Mason, OH 45040.
