Fillable Application for Group Health Insurance (Sanford Health Plan)

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Application for Group Health Insurance (Sanford Health Plan)

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The Application for Group Health Insurance (Sanford Health Plan) form is 4 pages long and contains:

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  • 91 check-boxes
  • 104 other fields

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File type: PDF

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HP-1151 (SVHP-1160) Rev. 5/2020 Fillable Non-Simplicity Group-no Pre-ex. P a g e | 1 of 4
Application for Group
Health Insurance
This section must be completed by Human Resource Representative.
Incomplete forms will be returned and may cause processing delays.
Group Name:_________________________ Group/Division Number:
Effective Date:_________________________ Date of Hire:
Reason for Enrollment: □New Hire □Open Enrollment □Late Entrant □Special Enrollment Reason:
Signature of Company Representative_____________________________________ Date:
Please send originals to: Sanford Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110
Employee Information
First Name, M.I., Last Name
Social Security #
Date of Birth (MM/DD/YY)
Mailing Address (Street Address)
City
Zip Code
County
E-mail Address
Primary Phone Number
Work Phone Number
Family Physician
Gender: □ Male □ Female Marital Status: □ Married □ Single □ Divorced/Separated □ Other
What is your primary language? □ English □ Spanish □ Other _________________________________________
Coverage Election
□ YES- I am electing coverage
Deductible Choice: _____________________________________________
Network Choice: □Broad □Tiered □Focused
□ NONE – I am declining coverage because I and/or my dependents have coverage through: □Spouse’s Group Health Plan □Other
Explain:_____________________________________________________________________________________
Dependent Information – List all family members to be covered. Use additional sheet, if needed.
First Name, M.I., Last Name
Gender
(M/F)
Date of Birth
(MM/DD/YY)
Social Security
#
Relationship
1
Full Time
Student
2
(Y/N)
Family Physician
Do all of the dependent(s) listed above reside at the same address as the employee? □ Yes □ No
If no, list dependent(s) name and address: _______________________________________________________________
Provide additional information if answered ‘Yes’ above:
1
For North Dakota and Minnesota applicants: If the unmarried parent of the grandchild is a covered eligible dependent and both the parent and grandchild are primarily
dependent on the subscriber. Grandchildren must reside with subscriber.
2
For South Dakota applicants: If the dependent is over age 26 and under age 30, and a full-time college student, please provide name of school/university, city and state:
___________________________________________________________________________________
2
For Iowa applicants: If dependent is a full-time college student, please provide name of school/university, city and state:
Other Insurance Information
Are you currently, or have you been previously enrolled with Sanford Health Plan?
Yes No If Yes, who? List ID# ______________________
Will you or any of your family members be covered by another health policy after the effective date of enrollment with Sanford Health Plan?
Yes No If yes, you must complete the following information to coordinate benefits.
Person Insured
Employer of Insured
Insurance Company
Policy Number
Effective Date
P.O. Box 91110
Sioux Falls, SD 57109
(605) 328-6800
(800) 752-5863
Fax: (605) 328-6811
sanfordhealthplan.com
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HP-1151 (SVHP-1160) Rev. 5/2020 Fillable Non-Simplicity Group-no Pre-ex. P a g e | 2 of 4
List covered family members:
Is anyone named in the application eligible for Medicare? □ Yes □ No Name/Medicare Number: ________________________
Health Assessment
Has anyone in this application for health insurance ever had, or ever been treated or diagnosed by a physician or medical
professional for any conditions listed below? Provide details in the section provided below.
Yes No AIDS or a positive HIV test
Yes No Allergy / Asthma
Yes No Back or Neck Disorder
Yes No Blood Disorder
Yes No Bone/Joint/Muscular Disorder
Yes No Cancer
Yes No Diabetes/Pancreatic Disorder
Yes No Digestive/Intestinal Disorder
Yes No Drug or Alcohol Abuse
Yes No Eating Disorder
Yes No Ear, Nose & Throat Disorder
Yes No Heart/Circulatory Disorder
Yes No High Blood Pressure
Yes No High Cholesterol
Yes No Infertility/Reproductive Organ Disorder
Yes No Kidney/Bladder/Urinary Disorder
Yes No Liver Disorder
Yes No Mental or Nervous Disorder
Yes No Migraine Headaches
Yes No Nervous System/Brain Disorder
Yes No Respiratory/Lung Disorder
Yes No Skin Disorder
Yes No Stroke
Yes No Tumor or Cyst
Yes No Current Pregnancy; due date __________
Are you or any dependent listed on this application a tobacco user? Yes No If yes, list who:_____________________
List any other condition, treated in the last 10 years, not mentioned above:________________________________________
Yes No In the last year, has anyone received medical treatment apart from routine physicals or immunizations?
Yes No Do you or any of your dependents take any medicines or require shots?
Yes No Do you or any of your dependents have treatments, tests, hospitalization or surgery planned in the future?
Are any of these conditions related to a workers’ compensation injury, motor vehicle accident or third party liability claim?
Yes No
If yes, explain:________________________________________________________________________________
If you checked yes to any health questions above, please complete this section. Use an additional page if needed and include your
signature and date.
Name of Person
Name of Condition
Date of Onset and
Duration of Treatment
Type of Treatment,
Medication, and Degree
of Recovery
Name and Address of
Physician
Conditions of Enrollment
I agree for myself and on behalf of my eligible dependents to the following conditions of enrollment in Sanford Health
Plan (hereafter referred to as the Plan).
1. We will abide by the rules and regulations of the Plan.
2. We will be bound by the eligibility requirements as stated in the Member Handbook, benefits, deductibles,
copayments, coinsurance, exclusions, limitations, and other terms of the health maintenance contract and
certificate of coverage.
3. We will complete and submit to the Plan such concepts, releases and other assignments as are reasonably
necessary for the Plan in accordance with its rights under the health maintenance contract and certificate of
coverage, to coordinate with other group health benefit plans or group insurance policies. I shall cooperate with
and assist the Plan with respect to such coordination of benefits.
4. We will pay any copayments, deductibles or coinsurance as is required by the health maintenance contract or
certificate of coverage directly to those providers who provide the health care services.
5. We acknowledge that we will be personally liable to the Plan for the usual and customary cost of any Health Care
Services received during a time we are not eligible for coverage under the Certificate of Coverage.
HP-1151 (SVHP-1160) Rev. 5/2020 Fillable Non-Simplicity Group-no Pre-ex. P a g e | 3 of 4
Special Enrollment Notice
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance or group health plan
coverage, you may be able to enroll yourself and your dependents in this plan if you or your dependent's other coverage).
However, you must request enrollment within 30 days after your or your dependents' other coverage ends (or after the employer stops contributing
toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and
your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.
To request special enrollment or obtain more information, contact our Customer Service Department at (605) 328-6800 or toll-free at (800) 752-
5863
Genetic Information Nondiscrimination Act of 2008 (GINA)
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Tile II from requesting or
requiring genetic information of an individual or family member of the individual , except as specifically allowed by this law. To comply with this law,
we are asking that you not provide any genetic information when responding to this request for medical information. ‘Genetic information’ as defined
by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or
an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family
member of an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Michelle’s Law
Federal law requires that we provide the following notice regarding Michelle’s Law [Public Law 110-381]. Please note that changes in federal law may
eliminate certain elements of Michelle’s Law, and the Plan intends to provide continuing coverage of Eligible Dependents up to age twenty-six (26),
irrespective of their student status, for Plan Years beginning on or after September 23, 2010.
A Dependent Child enrolled in, and attending an accredited college, university, trade, or secondary school at least (5) months each year will remain
covered if the Dependent takes a medically necessary leave of absence from school or changes to part-time status. The leave of absence must:
1. Be medically necessary;
2. Commence while the child is suffering from a serious illness or injury; and
3. Cause the child to lose coverage under the plan.
Students are only eligible as long as they were covered by their parent’s health insurance policy prior to diagnosis. Coverage will continue until the
earlier of one year from the first day of the leave of absence or the date on which coverage would otherwise terminate because the child no longer
meets the requirements to be an Eligible Dependent (e.g., reaching the plan’s limiting age).
You must provide a signed, written documentation from the Dependent Child’s treating Practitioner/Provider stating all of the following: 1) the
Dependent Child is suffering from a serious illness or injury necessitating a medical leave of absence; 2) the treating Practitioner/Provider certifies
such leave of absence is Medically Necessary; and 3) the dates when the Dependent will be either on a medically necessary leave of absence from
school or will be changing to part-time status due to a serious illness or injury.
Signature
On behalf of myself and my eligible dependents listed above, I hereby agree to the conditions of enrollment attached hereto. If
applicable, my employer is authorized to deduct from my earning the necessary premium contributions, if any, required of me.
Signature of Employee
Date
HIPAA Authorization for Pre-Enrollment Uses and Disclosures of Member Information
I hereby authorize the use or disclosure of personal health information about me as described below.
I authorize Sanford Health Plan to use the personal health information I have provided on the application form to determine my eligibility to obtain
coverage under the health benefits plan, for which I have applied, and to determine the rates and terms which apply to the plan/policy. I also authorize all
health care providers and pharmacy benefit managers who have provided treatment or other health care services to me to disclose all information regarding
my treatment to Sanford Health Plan. The following group of persons employed or working for Sanford Health Plan may use my personal health
information disclosed herein: employees of the Underwriting, Customer Service, Flex and Medical Management departments. The information which is
disclosed by health care providers may be used by Sanford Health Plan to determine my eligibility to obtain coverage under the health benefits plan, for
which I have applied, and to determine the rates and terms which apply to the plan/policy. I understand that I may revoke this authorization in writing at
any time, except to the extent that action has been taken by Sanford Health Plan in reliance on this authorization, by sending a written revocation to Sanford
Health Plan, Attn: Customer Service, PO Box 91110, Sioux Falls, SD 57109-1110. I understand that the information which will be provided under this
authorization is necessary for Sanford Health Plan to determine my eligibility for coverage under the health benefits plan and that Sanford Health Plan will
condition enrollment in the health benefits plan/policy on my providing this authorization, and my application may be denied if I refuse to provide this
authorization. I understand that if the person or entity that receives my personal health information is not a health care provider or health plan covered by
the federal privacy regulations, the information may be redisclosed by such person or entity and will likely no longer be protected by the federal privacy
regulations. In the case of this authorization, however, the information described above will be received by a health plan which is covered by the federal
privacy regulations, and will not be used or redisclosed except as described above, and the information will continue to be protected under the federal
privacy regulations.
Applicant Name or Legal Representative
1
(print)
Applicant Signature
Date
1
If you are the legal representative of the applicant and are not the parent of a minor, you must attach evidence of your authority to act as the applicant’s representative for this authorization to be valid (i.e. Power of Attorney).
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HP-1151 (SVHP-1160) Rev. 5/2020 Fillable Non-Simplicity Group-no Pre-ex. P a g e | 4 of 4
Health Plan Use Only
Enrollment Application Audit Checklist
Please check off each category after audit is complete. Circle if information is incorrect and return to enrollment
processor for corrections.
□ Social Security # □ Sex (Male/Female) □ Group #
□ Dependent student on review □ Effective Date □ Address
□ Date of hire □ Date of Birth □ Name spelling
□ Verify Network Choice □ Other insurance information □ Pre-Ex Determination
□ Other:_______________
Auditor: _______________________ Date:___________________
Processor:____________________ Date:________________
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Application for Group Health Insurance (Sanford Health Plan)

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Completed 20 May 2021

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