Enrollment Form Authorization

I request coverage for myself and/or any eligible dependent(s), as listed on this form, and authorize my employer to deduct the premium(s) from my compensation for the cost of the coverage(s).

For administration, eligibility, benefits, risk classification, fraud or misrepresentation, and audits purposes, I authorize the applicable carriers, legal representatives, and/or re-insurers, to release or obtain necessary medical records or claim information from any licensed physician, medical practitioner, hospital, clinic, or other medical or medically related facility or insurance company.

I give the carriers, their legal representatives, and any person and/or organization administering claims on behalf of the University permission to release to my employer or group policyholder a summary of claims incurred by my eligible dependent(s) and/or myself.

I understand that my authorized representative may receive a copy upon request. The summary of claims may be provided without identifying by name the person with their claim. The summary may include the nature of the condition, the date and nature of services rendered, the provider of the services, and/or the amount of the claim.

I understand and agree that, with the exception of medical emergency procedures, all medical plan services, in order to be covered at the highest benefit level, must be performed by either a participating provider or authorized by prior written referral. I will pay any required copayments directly to the health care provider.  I agree to be bound by all terms of the plan(s) under which I am applying for coverage. I agree that a copy of this authorization shall be valid as the original.

I certify that my benefit elections are final for the July 1 – December 31, 2018 shortened plan year period. I am aware that no changes will be accepted after April 9, 2018, unless the elections that ultimately display in WF@Work do not match the ones submitted on this form.  I will notify Human Resources of any discrepancies between the form what displays in WF@Work on April 18, 2018 by emailing AskHR@nullwfu.edu.