2015 ind Application w new plans 093014

INDIVIDUAL APPLICANT ENROLLMENT FORM – NEVADA RESIDENTS ONLY
For internal use only: Sales Rep: _________
Effective Date: ____/_____/____
I am (We are) requesting my (our) Application be effective the first of the month of: _____________________________.
Type of Application (Check one)
 Annual Open Enrollment
 Outside of Open Enrollment (No Qualifying Life Event)
Effective date is 1st of the month following 90 days after receipt
of application
 Qualifying Life Event
Date of Event: _____/_____/_____
Type of Event:
Birth or Adoption
Marriage / Divorce
Loss of Coverage
Other: ___________________
PLEASE PROVIDE ALL RESPONSES IN BLACK INK
Section 1. Plan Selection (Please select one medical plan only)
Health Plan of Nevada, Inc.: MyHPN Solutions
BRONZE HMO
 1
 2
Sierra Health and Life Insurance Co., Inc.: MySHL Solutions
BRONZE PPO
 1
 2
 3
 3
SILVER PPO
 1
 2
GOLD PPO
 1
 2
 3
PLATINUM PPO
 1
 2
BRONZE HSA
 1
 2
 3
SILVER HSA
 1
 4
SILVER HMO
 1
 2
 3
 4
 5
GOLD HMO
 1
 2
 3
 4
 5
PLATINUM HMO
 6
 1
 3
 6
 7
 8
 5
CATASTROPHIC PPO
 1
OPTIONAL PRODUCT OFFERINGS (Additional premium applies)
HPN Adult Vision Rider (age 19+) (check box to elect)

SHL Adult Vision Rider (age 19+) (check box to elect)

Nevada Pacific Dental HMO* (check box to elect)
*All dependents will be enrolled

Nevada Pacific Dental HMO* (check box to elect)
*All dependents will be enrolled

Section 2. Applicant Information Please write legibly
Marital Status:
 Single
 Married
 Divorced
 Widowed
 Domestic Partner (DP)
First Name: ____________________________________________MI: ______ Last Name: _______________________________________________
Street Address:___________________________________________________________ _________________________________________________
Street
Apt #
City
State/Zip
Billing Address: (If different than above)_________________________________________________________________________________________
Home Phone: (_______)___________________ Cell Phone: (_______)___________________ Business Phone (_______)_____________________
Applicant Email address: __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Emergency Contact Name:______________________________________________ Phone Number (______)_________________________________

Child Only Application - for Child Only Applications, please complete the information below:
Parent/Legal Guardian as responsible party: __________________________________________________ Phone: _________________________
Agency/Agent Information – Must be completed to receive commissions
Tax ID #_________________________
702-566-2048
Office Phone #: __________________________
702-810-8069
Cell Phone #______________________________
Chaoxia Yuan
IAM Inc
Agency Name:_____________________________________________________
Agent Name:___________________________________________
Henderson, NV 89074
223 N Pecos Rd Ste 120,
Street Address:________________________________________________________
City/State/Zip:_______________________________________
Form No. HPN-SHL-BlendedIndApp-Form(2015)
1
INDIVIDUAL APPLICANT ENROLLMENT FORM – NEVADA RESIDENTS ONLY
Section 3. Applicant and Eligible Family Member Information. Please list yourself and all Eligible Family Members applying for or changing
coverage. Only your spouse/DP and/or Eligible Children (up to age 26) may apply as Dependents.
This section must be completed for new Applicants and when adding an Eligible Family Member
1.
Full Name
First Name, Middle Initial, Last Name
Applicant:
Eligible
for
Medicare
A or B

Other coverage: If yes, carrier name & effective date
2.
Spouse/DP
Other coverage: If yes, carrier name & effective date
3.
Child:
Other coverage: If yes, carrier name & effective date
4.
Child:
Other coverage: If yes, carrier name & effective date
5.
Child:
Other coverage: If yes, carrier name & effective date
6.
Child:
Other coverage: If yes, carrier name & effective date
7.
Child:
Other coverage: If yes, carrier name & effective date

Social
Security
Number
Birth
Date
MM/DD/YY
Yes
No


Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No
Gender
Tobacco
Use 1


M
F


Yes
No


M
F


Yes
No


M
F


Yes
No


M
F


Yes
No


M
F


Yes
No


M
F


Yes
No


M
F


Yes
No
HPN Options Only
Primary
Care
Provider
OB/GYN
(PCP) 2 or
(For
Pediatrician Females)








1.
Within the past six months have you used tobacco regularly (four or more times per week on average excluding religious or ceremonial use)?
2.
If enrolling in an HPN Plan, select a Primary Care Physician (PCP) or Pediatrician from the HPN Provider Directory available at
www.myhpnonline.com. Females should also select an OB/GYN physician.
Form No. HPN-SHL-BlendedIndApp-Form(2015)
2
INDIVIDUAL APPLICANT ENROLLMENT FORM – NEVADA RESIDENTS ONLY
Section 4. Acknowledgements and Application Completion
1.
2.
3.
4.
5.
6.
7.
8.
9.
SIGNATURE REQUIRED – By signing this document:
I (We) attest that I (we) am (are) not eligible and/or enrolled in Medicare Part A and/or Part B at the time of this application.
I (We) hereby apply to HPN/SHL for coverage now being offered to my Eligible Family Member(s) and me, if any, as shown on page 2. I (We)
understand that this application is subject to acceptance by HPN/SHL and that if a policy is issued, services will be available subject to the terms,
exclusions, limitations and benefits described in the HPN/SHL Agreement of Coverage (AOC) and the applicable Attachment A Benefit Schedule
and any applicable Endorsements, Riders and Attachments thereto.
I (We) understand that I am (we are) entitled to a copy of this form.
I (We) understand that once the Applicant is approved and the policy issued, HPN/SHL cannot change the established Effective Date.
I (We) understand if I (we are) am not satisfied for any reason or if the premium rates are not acceptable, within ten (10) days of receiving the AOC,
I (we) may return the AOC materials and request a full refund of the premium paid, less any claims paid, if applicable.
I (We) understand that if I (we) perform an act or practice that constitutes fraud or, if I (we) make any intentional misrepresentation of material fact,
HPN/SHL has the right to rescind coverage and declare coverage under the Plan null and void as of the original Effective Date of coverage and
refund any applicable premium.
I (We) understand that if I am (we are) applying for individual coverage outside the annual Open Enrollment. I am (we are) subject to a waiting
period of 90 (ninety) days after the date on which the application was received. I (We) understand that the coverage becomes effective upon the
first day of the month immediately following the date in which the waiting period is satisfied and is not retroactive to the date on which the
Application was received. Once your policy is issued, your Effective Date will be communicated by HPN/SHL.
I (We) understand HPN/SHL has the right to adjust premiums for this Agreement after providing sixty (60) days prior notice to the Applicant. Any
such adjustment will apply to all Applicants in the same class.
I (We) understand that the payment submitted with this Application will be processed at the time of approval and policy issuance.
I (We) represent that all statements and answers in this application, including any attachments, are true and complete to the best of my (our)
knowledge. I (We) agree that this shall be the basis of my (our) acceptance of membership. I (We) understand when information provided to HPN/SHL
in this Individual Applicant Enrollment Form is determined to be untrue, inaccurate, or incomplete, HPN/SHL shall have the right to terminate and/or
rescind coverage.
I (We) authorize HPN, SHL and/or UHC and Affiliates to obtain, use and disclose my (our) medical, claim or benefit records, including any individually
identifiable health information contained in these records. I (We) understand these records may contain information created by other persons or entities
(including health care providers) as well as information regarding the use of drug, alcohol, HIV/AIDS, mental health (other than psychotherapy notes),
sexually transmitted disease and reproductive health services. I (We) authorize any health care provider, pharmacy benefit manager, other insurer or
re-insurer, hospital, clinic or other medical facility, health care clearinghouse, and any of their affiliates, representatives or business associates, to
disclose my information to UHC and Affiliates. I (We) understand this authorization is voluntary and I (we) may refuse to sign the authorization. I (We)
understand I (we) may revoke this authorization at any time by notifying UHC and Affiliates in writing at the address provided, except to the extent that
action has already been taken in reliance on this authorization. I (We) further understand the information I (we) authorize a person or entity to obtain
and use may be redisclosed and no longer protected by the Federal Privacy Rule. This authorization, unless revoked earlier, shall remain in effect for a
period of thirty (30) months from the date signed below.
I (We) understand that Nevada requires specific authorization from the applicant agreeing to arbitration. If I am (we are) dissatisfied with the findings of
an Independent Medical Review, I (we) shall have the right to have the dispute submitted to binding arbitration before an arbiter under the commercial
arbitration rules applied by the American Arbitration Association.
It is important that you carefully read and fully understand the following:
All Applicants age 18 and over must personally read, agree to, and sign as indicated. I (We) understand and accept this Application.
Applicant/Court Appointed Legal Guardian Signature:__________________________________________________Date____________________
Spouse/DP Signature:_____________________________________________________________________________Date____________________
Eligible Family Member Signature (18 and over): ______________________________________________________Date____________________
Eligible Family Member Signature (18 and over): ______________________________________________________Date____________________
Eligible Family Member Signature (18 and over): ______________________________________________________Date____________________
WARNING: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant
for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Nevada Division of Insurance.
Form No. HPN-SHL-BlendedIndApp-Form(2015)
3
INDIVIDUAL APPLICANT ENROLLMENT FORM – NEVADA RESIDENTS ONLY
Section 5. Initial One Time Payment Only – Optional Credit Card Premium Payment
You may choose to make your initial premium payment by check, money order or credit card. A one-time credit card payment is available for your first
premium payment. If choosing to pay by credit card, you must complete all of the following information:
Applicant/Member Name:____________________________________________________
VISA
Master Card
AMEX
Amount To Charge Upon Policy Issuance $___________________ (Must be completed)
Credit Card # ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
Exp Date: (mm/yyyy) _____________
I authorize HPN/SHL to bill my VISA, MasterCard or AMEX account for the payment amount shown above at the time my Application is approved. I
understand that the amount authorized will be charged in its entirety upon approval of this Application and may or may not be my final
monthly premium. I am responsible for any premium due on my account. Any credits will be applied to future billings.
Cardholder Name (as it appears on the credit card)
Form No. HPN-SHL-BlendedIndApp-Form(2015)
Cardholder Signature (please sign)
Date
4
INDIVIDUAL APPLICANT ENROLLMENT FORM – NEVADA RESIDENTS ONLY
PLEASE RETAIN THIS PAGE TO REGISTER FOR @YourService
Instructions to sign up for Paperless Invoice or to make monthly payments online.
It’s fast, it’s easy, it’s paperless!
You are eligible sign up for a paperless invoice and/or make your monthly premium payment via our online member center: @YourService.
Once you have received your member ID number, please register at www.myaysonline.com by clicking on the “Create an Account” link.
You may opt into the paperless invoice program by clicking on the “My Profile & Preferences” section and selecting “Yes, I prefer paperless
invoice”.
You will receive a monthly email alert when a new invoice is available to view on @YourService. You will be able to pay online via electronic
check, credit card or money market account.
If you have any questions about this service, please contact the HPN/SHL Billing Department at 702-242-7764.
UnitedHealthcare and Affiliates
Medical Coverage provided by:
Health Plan of Nevada, Inc., a UnitedHealthcare Company
Sierra Health and Life Insurance Co., Inc. a UnitedHealthcare Company
P.O. Box 15645
P.O. Box 15645
Las Vegas, NV 89114-5645
Las Vegas, NV 89114-5645
Member Services: (702) 242-7300 or 1-800-777-1840
Member Services: (702) 242-7700 or 1-800-888-2264
Optional Adult Vision Coverage provided by:
Optional Dental HMO Coverage provided by:
Health Plan of Nevada, Inc., a UnitedHealthcare Company or
Nevada Pacific Dental, a UnitedHealthcare Company
Sierra Health and Life Insurance Co., Inc. a UnitedHealthcare Company
2720 N. Tenaya Way
Las Vegas, NV 89128
P.O. Box 15645
(800) 926-0925
Las Vegas, NV 89114-5645
HPN Member Services: (702) 242-7300 or 1-800-777-1840
SHL Member Services: (702) 242-7700 or 1-800-888-2264
Form No. HPN-SHL-BlendedIndApp-Form(2015)
5

Download Report