22411-0813
Section E: Change Authorization
Plan Coverage Terms
I hereby authorize the changes to my Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue and/or Health Options, Inc.,
D/B/A Florida Blue HMO contract that is selected on this form. I understand and agree that the changes will not be effective
until this application is accepted by Florida Blue and/or Florida Blue HMO.
I authorize my employer to deduct from my earnings my premium contribution, if any, including any additional amounts required
as a result of the changes indicated on this Health Change Application. I understand all of the following:
1. If my coverage/membership is to be issued and continued, I must meet all the group contract’s requirements;
2. If my dependents’ coverage/membership, if any, is to be issued and continued, my dependents must meet all the group
contract’s requirements;
3. If I must pay part or all of the premium, coverage/membership shall not become effective until Florida Blue and/or Florida
Blue HMO accepts this application and assigns an effective date.
I understand that membership granted to persons herein shall be subject to all provisions and limitations of the group contract.
I am aware that a change in coverage of dependents may affect the amount deducted from any wages (if any) for coverage/
membership, and I hereby authorize such a change.
If I am enrolling in a high-deductible health plan designated for use with a Health Savings Account (HSA) under Internal
Revenue Service Code section 223, I recognize and authorize Florida Blue to exchange certain limited information obtained from
this application with its preferred financial partner(s) for the purposes of initial enrollment in, and administration of, HSAs.
I understand that if I am enrolling in an HSA qualified High Deductible Health Plan and I elect to receive Prior Carrier Credit
under Florida law, my plan may no longer qualify as an HSA compatible plan.
General Terms
I AGREE that in the event of any controversy or dispute between Florida Blue and/or Florida Blue HMO, I and my dependents
must exhaust the appeal and/or grievance processes in the benefit/member handbook issued to me.
I understand that my employer is not an agent of Florida Blue and/or Florida Blue HMO. I also understand that my employer is
responsible for notifying all employees of:
1. Effective dates;
2. All termination dates;
3. Any conversion, COBRA or ERISA rights or responsibilities; and
4. All other matters pertaining to coverage/membership under the group contract.
When an overpayment is made, I authorize Florida Blue and/or Florida Blue HMO to recover the excess from any person or
entity that received it.
I acknowledge that Florida Blue and/or Florida Blue HMO coverage/membership is contingent upon the complete, accurate
disclosure of the information requested on this form.
I acknowledge that, if I apply for Florida Blue and/or Florida Blue HMO coverage/membership later, coverage/membership may
not be available until the next annual open enrollment or special enrollment period. I acknowledge that any applicable credit
toward a health care Pre-existing Condition Exclusion Period is contingent upon the complete and accurate disclosure
of information.
I represent that the statements on this application are true and complete to the best of my knowledge and belief.
I understand and agree that misrepresentations, omissions, concealment of facts, or incorrect statements may result in denial
of benefits and/or termination of coverage/membership. I agree to be bound by the group contract’s terms and conditions.
I understand that a copy of the Summary of Benefits and Coverage (SBC) can be obtained by contacting my
Group Administrator.
Signature:
Date:
Health and vision insurance is offered by Blue Cross and Blue Shield of Florida, Inc., D/B/A Florida Blue. HMO coverage is offered by Health
Options, Inc., D/B/A Florida Blue HMO, an HMO subsidiary of Florida Blue. These companies are Independent Licensees of the Blue Cross and
Blue Shield Association.
I understand that any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of
claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
