M35G49MNAGNJ01 01E Page 8 of 9
First Name Last Name
OLE
My signature indicates I have read and understand all contents of this Application Form and have answered
all questions to the best of my ability.
______________________________________________________________ __________________
Your Signature (required) Today’s Date (required)
Month Day Year
Note: If you are signing as the legal representative (e.g., POA, Guardian, Conservator, etc.) for the applicant, please send a complete
copy of the appropriate legal documentation and check this box.
10
Authorization and Verification of Application Information (continued)
• I understand coverage, if provided, will not take effect until issued by UnitedHealthcare Insurance Company, the actual
premium is not determined until coverage is issued and that this Application Form and payment of the initial premium does
not guarantee coverage will be provided.
• I acknowledge receipt of the Guide to Health Insurance for People with Medicare and the Outline of Coverage.
If the Application Form is being completed through an Agent or Broker:
• I understand an agent or broker discussing Plan options with me is appointed by UnitedHealthcare Insurance Company,
and may be compensated based on my enrollment in a Plan.
• I understand that an agent or broker cannot change or waive any terms or requirements related to this Application Form
and its contents, underwriting, premium or coverage and cannot grant approval.
Authorization for the Release of Medical Information
I authorize UnitedHealthcare Insurance Company and its affiliates (“The Company”) to obtain from any health care provider,
licensed physician, medical practitioner, hospital, pharmacy, clinic or other medical facility, health care clearinghouse,
pharmacy benefit manager, insurance company, or other organization, institution or person, or The Company’s own
information, any data or records about me or my mental or physical health. I understand the purpose of this disclosure
and use of my information is to allow The Company to determine my eligibility for coverage and rate. I understand this
authorization is voluntary and I may refuse to sign the authorization. My refusal may, however, affect my eligibility to enroll
in the health plan or to receive benefits, if permitted by law. I understand the information I authorize The Company to obtain
and use may be re-disclosed to a third party only as permitted under applicable law, and once re-disclosed, the information
may no longer be protected by Federal privacy laws. I understand I may end this authorization if I notify The Company, in
writing, prior to the issuance of coverage. After coverage is issued, this authorization is not revocable. If not revoked, this
authorization is valid for 24 months from the date of my signature.
Please see “Your Guide” to determine if the following pre-existing condition waiting period applies to you.
I understand the plan will not pay benefits for stays beginning or medical expenses incurred during the first
3 months of coverage if they are due to conditions for which medical advice was given or treatment
recommended by or received from a physician within 3 months prior to the insurance effective date.