health net california individual family application (fillable) 2011

8/7/2019 Health Net California Individual Family Application (fillable) 2011

1/18

Application must be typed or completed in blue or black ink. THE APPLICATION MUST BE COMPLETED BY THE APPLICANT.NEITHEr BrOkEr NOr ANY OTHEr PErSON MAY COMPLETE THE STATEMENT O HEALTH Or SIgN THISAPPLICATION AND AgrEEMENT ON BEHAL O THE APPLICANT. The Statement o Health can be completed by theapplicant o mino dependents.

I you are applying or coverage with a spouse or domestic partner who is younger, indicating him or her as the Primary Applicant may qua

you or a more avorable rate. I you choose dierent plans or you and a spouse/domestic partner, Single rates will apply.Please see Pat VIII i applicant does not ead/wite Enlish. The Individual & Family Enrollment Application is available in Chineseand Spanish language versions.

Please conside you options caeully beoe ailin to maintain o enew coveae o a child o whom you ae esponsible. I youattempt to obtain new individual coveae o that child, the pemium o the same coveae may be hihe than the pemium youpay now.

1IFPAPP12011-2 SAP 602271

Primary Applicants Last Name First Name MI MaleFemale

Home Address

City State ZIP County applicant resides in

Billing Address (I you want your bill sent to an address dierent rom your home address; only your bill will be sent to this address.)

Home Phone Number

( )

Work Phone Number

( )

Email address

Primary Applicants Birth Date (mo/day/year)

/ /

Place o Birth Primary Applicants Social Security Number:

Height Weight (

In the past 6 months, have you been a resident o

the United States? Yes No

I No, where was your last residence?

Please select your language preerence (optional): English Spanish ChineseOccupation:

Would you be interested in other Health Net or aliated entities, products and services? Yes No

May we contact you by email? Yes No If Yes, a Health Net representative or Authorized Agent will contact you.

How did you hear about Health Nets Individual and Family coverage?

Radio Mail Billboard Newspaper Yellow Pages Broker Internet Other: ________________________

Part I: tell us about yourself

ValueNet Ng

HSA (Compatible Plan) Optimum Advantage HSA 4500 NG

I you have applied or Individual PPO coverage and do not meet the underwriting requirements or preerred premiums or the PPO plan owhich you applied, Health Net may elect to oer you our Modifed Issue PPO option. The Modied oer may be a plan that will have a that could be substantially hihe than the standard rate or which you applied. I you meet the underwriting requirements or Modied IsPPO, you will be automatically enrolled unless otherwise specied. Please check this box i you do not want to be automatically enrolled intoModifed Issue PPO option.

NO, do not enoll me in the Modifed Issue PPO option.

Add Tem Lie Insuance Coveae (Pat V must be completed.)

Add Dental and Vision Plus I you ae selectin dieent medical plans o each amily membe and notin these choices inPat III, please also note in Pat III which amily membes you wish to enoll in Dental and Vision Plus.

Part II: Choose your Plan

IndIvIdual & FamIly

PPO EnrOllmEnt aPPlIcatIOn

To get a quote or to apply online please visit http://www.healthnetworkinsurance.com/ca-get-quote


2/182FPAPP12011-2 SAP 6022718 (1/

Pimay Applicants Social Secuity Numbe

Pimay Applicants Name:

a. reQuesteD effeCtIVe Date

1sto the month 15th o the monthPlease note date: ________________/01/________________ Please note date: ________________/15/_______________

b. reason for aPPlICatIon

amily type: Applicant Applicant and Spouse/Domestic Partner1 Applicant and Child Applicant and ChildrenFamily: Applicant, Spouse/Domestic Partner and Child(ren) (1Pleasecirclespouse or Domestic Partner)

Enollment type: New Enrollment Change Plan2 Add Dependent 2Member ID number (listed on your ID card): _____________C. bIllIng oPtIons

Please select a billing option. This billing option does not apply to Term Lie, which is billed and administered separately.

ist Pemium Payment (select one)Automated Bank Drat (Please complete the Simple Pay Option section.)Pay by Check (Please include completed check and send with Application. Amount must match monthly premium.)Credit Card (Please complete the credit card section.)

Onoin Monthly Pemium Payments (select one)Automated Bank Drat (Please complete the Simple Pay Option section.)Monthly BillCredit Card (Please complete the credit card section.)

Yes No

Part III. famIly member(s) to be enrolleD

Health Net oers the ollowing coverage options:1. Single Coverage: I you are applying or coverage just or yoursel, complete Part II.2. Family Coverage (applicant plus one or more dependents): For amily coverage, you need to ll out both Parts II and III. Please complete

Pat IV o childen unde 19 yeas o ae.With amily coverage, you have the option o enrolling in the same plan or choosing dierent plans or dierent amily members. Please nothat when each amily member chooses a dierent plan, Single rates will apply to each amily member. To speciy dierent plans or dierenamily members, be sure to write the plan name you are choosing or each amily member in the spaces provided in Part III.

1. List all eligible amily members to be enrolled other than you. I a listed amily members last name is dierent rom yours, please explain ona separate sheet o paper.

2. For Domestic Partner coverage, all requirements or eligibility, as required by the applicable laws o the State o Caliornia, must be met and ajoint Declaration o Domestic Partnership must be led with the Caliornia Secretary o State.

3. How to make dierent plan choices:

a. I you wish to choose dierent medical and Dental and Vision Plus coverage or each amily member, please complete the Dental and Vision Pluscoverage questions.3

b. Health Net bills to only one address per Applicant. Thereore, to be processed under one Applicant, all amily members must be billed to thesame address.

c. See Part V to enroll in Supplemental Term Lie Insurance.

relation Last Name ist Name MI Social Secuity Date o Bith Place o Bith Height/Numbe Weight (lbs.)

DEPENDENT 1Husband WieDomestic PartnerSon DaughterMedical plan choice o each amily membe i dieent3 Add Dental and Vision Plus

For additional dependents please attach another sheet with the requested inormation.Single rates apply when you enroll each amily member in a dierent medical plan.

relation Last Name ist Name MI Social Secuity Date o Bith Place o Bith Height/Numbe Weight (lbs.)

DEPENDENT 2Son DaughterMedical plan choice o each amily membe i dieent3 Add Dental and Vision Plus

Yes No

Please ax comleted application to 800-376-4703


3/18

3IFPAPP12011-2 SAP 6022718 (

Dependent 1 Dependent 2

A. My child(en) ae applyin duin an Open Enollment Peiod. (Proo o date o birth may be required.)

Yes No Yes No

Duin the pevious 90 days, have you o any applicants beencoveed by health insuance? I Yes, poo ofpio coveae isequied.

Yes No Yes No

Dependent 1 Name Insurer Name Policyholder/Member ID No. Group No.

Plan Name State Most recent coverage start date End Date

Dependent 2 Name Insurer Name Policyholder/Member ID No. Group No.

Plan Name State Most recent coverage start date End Date

Dependent 1 Dependent 2

B. My child(en) ae cuently without coveae and ae applyin duin aLate Enollee Peiod. Please select the appopiate Qualiyin Event below.

Yes No Yes No

Qualiyin EventsI your child(ren) did not enroll during an Open Enrollment period they mayenroll within 63 days ater any o the ollowing qualiying events. Please selectthe appropriate box and attach supporting documentation.

a) The child lost dependent coveae due to:

i) The temination o chane in employment status o the child o thepeson thouh whom the child was coveed. (Proo o loss o status, such asan employer letter or collateral showing dependent criteria, will be required.)

ii) The loss o an employes contibution towad an employees odependents coveae. (Proo o loss o contribution, such as an employerletter or collateral showing employers contributions, will be required.)

iii) The death o the peson thouh whom the child was coveed asa dependent.

iv) Leal sepaation o divoce. (Proo o loss o coverage, such as aCerticate o Creditable Coverage or loss o coverage letter rom theemployer or insurer will be required.)

v) The loss o coveae unde the Healthy amilies poam, Access oInants and Mothes (AIM) poam o the Medi-Cal poam.(Proo o loss o coverage, such as termination letter rom these programs,

will be required.)b) The child became a esident o Calionia duin a month that was not the

childs bith month.

c) The child was bon as a esident o Calionia and did not enoll in themonth o bith.

d) The child is mandated to be coveed pusuant to a valid state o edealcout ode. (As proo, a copy o the court order will be required.)

e) The child was adopted. (As proo, a copy o the legal adoption document willbe required.)

Part IV. sPeCIal enrollment for ChIlDren unDer 19 years of age



Your children under 19 years o age are eligible to enroll in an Individual & Family Planduring the ollowing periods and cannot be declined due to a pre-existing medical condition.Please complete one o the applicable sections below.



4/18

4IFPAPP12011-2 SAP 6022718

Part V. InDIVIDual term lIfe InsuranCe Complete this section only i you wish to apply o lie insuance coveaLie insuance coveae is dieent and sepaate om the PPO health cae coveae peviously discussed in this Application.The Primary Applicant and/or any dependents that are approved or a Health Net PPO medical plan will also qualiy or Term Lie coverag

Applicants under the age o one year and Applicants being oered Modied Issue or HIPAA plans are ineligible or Term Lie Insurance.Coverage is optional and can be purchased at an additional charge.

This insurance also is not intended to replace any Lie Insurance Policy currently in orce. I you would like supplemental Term Lie coverag1. Please list all amily members applying or Term Lie Insurance Coverage (available or ages 164).

2. Lie insurance requires an additional premium. You will be billed or the premium ater enrollment is conrmed by Health Net.3. Complete the beneciary inormation. You can have one or more beneciaries. I you have more than one, the percentages must add up to 10

Name o amily Membe/ull Name relationship to Pimay Applicant Bithdate (mo/day/yea) Amount

$10,000$20,000$30,000

$40,0$50,0

Sel

Benefciay Name Benefciay relationship Pecentae

Sinatue o Applicant Date


$10,0004

$20,000$30,000

$40,0$50,0Dependent 1


Sinatue o Spouse/Domestic Patne o Dependent 18 yeas o ae o olde Date


$10,0004$20,000$30,000

$40,0$50,0

Dependent 2


Sinatue o Dependent 18 yeas o ae o olde Date

4$10,000 is the maximum amount or children age 117.

A. For applicants age 19 and older, during the previous 63 days, have you or any applicants been covered by health insurance? Yes

B. Have you or any applicants been covered under a Health Net o Caliornia Plan or Health Net Yes Lie Insurance Company Policy in the last 5 years?I you answered Yes to A or B above, please provide the ollowing inormation or each applicant:

Part VI. PrIor health CoVerage

Applicant Name Insurer Name Policyholder/Member ID No. Group No.

Plan Name State Most recent coverage start date End date





Pimay Applicants Social Secuity Num




5/18

5FPAPP12011-2 SAP 6022718 (1/

C. HIPAA guaanteed Issue CoveaeI you do not qualiy or the Individual PPO plans, you may be considered or coverage under the HIPAA Guaranteed Issue plans.The HIPAA Guaranteed Issue plans do not require medical underwriting and the rates are higher compared to the other Individual PlanI I qualiy, please oer the HIPAA coverage and send complete details regarding my options and rates. Yes No

1. Have you had a total o at least 18 months o health care coverage (including COBRA or Cal-COBRA, i applicable) Yes Nowithout more than a 63-day break (excluding any employer-imposed waiting periods) in coverage? Please note that

you must apply or HIPAA coverage within the 63-day break ater your group health care coverage (including COBRAor Cal-COBRA, i applicable) ended.

2. Was your most recent coverage through a group health plan (COBRA and Cal-COBRA are considered Yes Nogroup coverage)?

3. Currently are you eligible or coverage under a group health plan, Medicare or Medicaid? Yes No(If Yes, you are not eligible for HIPAA coverage.)

4. Was your most recent coverage terminated because o nonpayment or raud? Yes No

5. Were you eligible under COBRA or Cal-COBRA? Yes No

Yes, start date: _______________________________ end date: _______________________________

I Yes, did you accept and use up all benets that were available? Yes No

I No, please explain: ______________________________________________________________________________________________________________________________________________________________________

Part VI. PrIor health CoVerage(continued)

Part VII. (a) statement of healthAll questions must be answeed.THE STATEMENT O HEALTH SECTION MUST BE COMPLETED Or EACH AMILY MEMBEr APPLYINg Or COVErAgEven thouh you childen unde 19 yeas o ae cannot be declined due to pe-existin medical conditions, you ae equied to complete tStatement o Health o each o you childen unde 19 yeas o ae o whom you ae equestin enollment because the monthly pemiumo thei coveae will be detemined by Health Nets eview o thei medical histoy.Check the appropriate Yes, No or Unsure box or each applicant. I you need additional copies o this Statement o Health section, pleasecontact your Health Net agent/broker who represents you or call Health Net at 1-800-909-3447. Please answer all questions Yes, No or UnsureI YES o UNSUrE, PLEASE CIrCLE THE SPECIIC CONDITIONS and complete Pat VII (B). For the purposes o this Statement oHealth, a health care provider or practitioner is any health care proessional capable o rendering any kind o health care service.Applicants or HIPAA-only coverage should complete the Health Net HIPAA Enrollment Application. See Part VI (C) or HIPAA eligibilitynormation and how to obtain inormation regarding HIPAA coverage, including the HIPAA Enrollment Application. HIPAA law guaranteescoverage, and applicants or HIPAA-only are not required to complete a Statement o Health.

genetic Inomation Non-discimination Act o 2008 (gINA) Compliance Statement: This Statement o Health is not a request or genet

normation. In answering these questions you should not include any genetic inormation. That is, please do not include any amily medical histoor any inormation related to genetic testing, genetic services, genetic counseling, or genetic diseases or which you believe you may be at risk.

NOTICE: You must povide tuthul and complete answes to the ollowin questions to the best o you ability. Even i you cuentlyhave health coveae o had pio coveae with Health Net, you must ully disclose and answe all health histoy questions. We aeelyin on the inomation you povide to detemine whethe you ae eliible o coveae. Duin the fst 24 months you aecoveed, we have the iht to eview all o you medical ecods to veiy the accuacy o you inomation. I coveae is issued, wemay not late escind coveae, except that any audulent o willul nondisclosue o misepesentation in the Application mateialso a mateial act is cause o disenollment and escission o the Insuance Policy. I we escind coveae o audulent o willulmisepesentation o nondisclosue o mateials acts, we may evoe you coveae as i it neve existed and you will lose healthbenefts includin coveae o teatment aleady eceived. This means that we may ecove om you any amounts paid om theoiinal date o coveae. o additional inomation eadin escission o membeship, see Pat X, Conditions o Enollment.

PrimaryApplicant Dependent1 Dependen2

1) During the past 12 months have you seen a health care provider(s) or practitioner(s),had a physical exam, laboratory test(s), EKG, X-ray(s), MRI, CT scan, PET, EEG,CAT scan, sonogram, ultrasound, mammogram, biopsy, colonoscopy, endoscopy,upper GI tests or series, urine test, or blood test(s) (other than an HIV test)?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

2) Within the past 2 years, have you consulted with a health care provider(s) orpractitioner(s) or, or been diagnosed with, or been treated or any o the ollowing:

A. Bursitis, arthritis, gout, muscle or tendon pain? Yes NoUnsure

Yes NoUnsure

Yes Unsure





6/18

6IFPAPP12011-2 SAP 6022718

PrimaryApplicant

Dependent1

Depende2

B. Chest pain, pneumonia, shortness o breath, pain or diculty breathing, sleepapnea, or dicult chewing or swallowing?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

C. Acne, rosacea, psoriasis or keratosis, or eczema? Yes NoUnsure

Yes NoUnsure

Yes Unsu

D. Jaundice, chronic diarrhea, unintentional or unexplained weight loss? Yes NoUnsure

Yes NoUnsure

Yes Unsu

E. Dizziness? Yes NoUnsure

Yes NoUnsure

Yes Unsu

F. Recurrent or chronic pain (including back pain)? Yes NoUnsure

Yes NoUnsure

Yes Unsu

G. Ear inection (otitis), sinusitis, deviated nasal septum, TMJ (temporomandibularjoint disorder), tonsillitis, or allergies?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

H. Asthma? Yes NoUnsure

Yes NoUnsure

Yes Unsu

I Yes, have you been hospitalized or been to an emergency room in the past24 months?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

I Yes, have you received any adrenaline or epinephrine injections? Yes NoUnsure

Yes NoUnsure

Yes Unsu

I. Thyroid disorder? Yes NoUnsure

Yes NoUnsure

Yes Unsu

3) During the past 5 years, have you consulted a health care provider(s) or practitioner(s),or any condition or symptom or which a diagnosis has not been established?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

4) During the past 5 years, have you consulted a health care provider(s) or practitioner(s)or any condition or symptom or which you have not been made aware o the causeor diagnosis?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

5) During the past 5 years, have you consulted a health care provider(s) or practitioner(s)or any condition or symptom or which you have been advised to have diagnostictest(s), treatment(s), surgery or hospitalization?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

6) Are you waiting or the results o any diagnostic tests? Yes NoUnsure

Yes NoUnsure

Yes Unsu

7) During the past 5 years, have you received Medicare benets or any other disabilitybenets as a result o disability or chronic illness or condition?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

8) Within the last 5 years, have you consulted with a health care provider(s) orpractitioner(s) or, or been diagnosed with, or been treated or any o the ollowing:

A. High or low blood pressure, hypertension, high cholesterol, phlebitis, Raynaud'sdisease, cal pain when walking, loss o consciousness, seizure disorder, headaches,

anemia, varicose veins, or paralysis?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

B. Pyelonephritis, kidney stones, or kidney, bladder, or urinary tract disorder(s)? Yes NoUnsure

Yes NoUnsure

Yes Unsu

C. Genital herpes, HPV (Human Papilloma Virus), genital or anal warts, or any othersexually transmitted disease?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

D. Carpal tunnel syndrome, osteopenia, osteoporosis, or muscle/bone/tendon/joint/vertebral disc injury or disorder(s)?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

E. Pancreatitis, ulcers, spastic colitis, hemorrhoids, hernia or gallbladder, liver,stomach, intestines, or esophagus disorder(s)?

Yes NoUnsure

Yes NoUnsure

Yes Unsu

Part VII. (a) statement of health(continued)





7/18

7FPAPP12011-2 SAP 6022718 (1/

PrimaryApplicant

Dependent1

Dependent2

F. Cyst(s), lump(s), or tumor(s) in any part o the body? Yes NoUnsure

Yes NoUnsure

Yes Unsure

G. Nervous, mental, emotional or behavioral disorder or panic attack(s)? Yes No

Unsure

Yes No

Unsure

Yes

UnsureH. Anxiety, depression, Epstein-Barr virus, chronic atigue syndrome, attention decit

disorder, or ADHD? Yes No

Unsure Yes No

Unsure Yes

Unsure

I. Developmental delay, premature birth, club oot, clet lip or palate? Yes NoUnsure

Yes NoUnsure

Yes Unsure

J. Glaucoma, cataracts or retinal degeneration? Yes NoUnsure

Yes NoUnsure

Yes Unsure

K. Male reproductive system: disorder o the prostate, inections, impotency, sexualdysunction, or male reproductive system disorder(s)?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

L. Female reproductive system: disorder o the breast, repeated breast biopsy, bleeding/drainage rom the nipple, broid tumors, menstruation disorders, abnormal Paptest, inections, abnormal bleeding, endometriosis, disorder o the ovaries, or emalereproductive system disorder(s)?

Yes No

Unsure

Yes No

Unsure

Yes

Unsure

9) Have you ever consulted with a health care provider(s) or practitioner(s) or, or beendiagnosed with, or been treated or any o the ollowing:

A. Manic depression, bipolar disorder, schizophrenia, obsessive compulsive disorder,suicide attempt, or eating disorder?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

B. Cancer, melanoma, leukemia, bone marrow transplant, Kaposis sarcoma,Hodgkin's disease, enlarged lymph nodes, or any other malignancy?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

C. Cerebral palsy, Alzheimer's disease, Parkinson's disease, stroke, or brain or nervoussystem disorder(s)?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

D. Heart attack, angina, heart murmur, heart valve replacement, irregular heart beat,palpitations, peripheral vascular disease, blood clot, poor circulation, pacemaker,shunt, heart disease, heart valve disorder, or heart, cardiovascular, or circulatorydisorder(s)?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

E. Emphysema, chronic obstructive pulmonary disease (COPD), pneumocystis cariniipneumonia, cystic brosis, tuberculosis or coughing up blood?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

F. Colitis, ulcerative colitis, Crohn's disease, cirrhosis, liver disease, hepatitis, or gastricbypass surgery?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

G. Inertility (inertility is dened as either (1) the presence o a demonstratedcondition recognized by a licensed physician and surgeon as a cause o inertility, or(2) the inability to conceive a pregnancy or to carry a pregnancy to a live birth atera year or more o regular sexual relations without contraception)?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

H. Ankylosing spondylitis, spondylosis, herniated, ruptured or bulging disc,rheumatoid arthritis, sclerodoma, joint replacement, or xation device(s)(pins, plates, rods)?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

I. Amyotrophic lateral sclerosis (ALS), Lou Gehrigs disease, multiple sclerosis,muscular dystrophy, Downs syndrome, or any congenital disorder?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

J. Diabetes, adrenal disorder, lupus, endocrine or metabolic disorder? Yes NoUnsure

Yes NoUnsure

Yes Unsure






8/18

8IFPAPP12011-2 SAP 6022718

PrimaryApplicant

Dependent1

Dependen2

K. Alcoholism, alcohol or substance abuse/dependency? Yes NoUnsure

Yes NoUnsure

Yes Unsur

L. Acquired Immune Deciency Syndrome (AIDS) or AIDS Related Complex (ARC)?(Note: Caliornia law prohibits an HIV test rom being required or used by health

care service plans or insurance companies as a condition o obtaining coverage.)

Yes NoUnsure

Yes NoUnsure

Yes Unsur

M. Breast implants, reconstructive or cosmetic surgery, or any other prosthesisor implant?

Yes NoUnsure

Yes NoUnsure

Yes Unsur

N. Hemophilia or blood or bleeding disorder(s)? Yes NoUnsure

Yes NoUnsure

Yes Unsur

O. Organ transplant? Yes NoUnsure

Yes NoUnsure

Yes Unsur

10) During the past 12 months, have you had a physical injury or experienced reoccurringpain or symptoms that have not been evaluated by a licensed health care provider orpractitioner or or which you plan to have evaluated by a licensed health care provideror practitioner?

Yes NoUnsure

Yes NoUnsure

Yes Unsur

11) Within the past two years, have you visited or consulted a physician, psychiatrist,chiropractor, physician assistant, nurse practitioner, physical therapist, or otherlicensed health care provider or practitioner that has not been disclosed elsewhere onthis Application?

Yes NoUnsure

Yes NoUnsure

Yes Unsur

12) Are you currently taking prescription medication?

I Yes, please complete Part VII (B).

Yes NoUnsure

Yes NoUnsure

Yes Unsur

13) Have you been prescribed or taken any prescription medication during the past12 months?

Yes NoUnsure

Yes NoUnsure

Yes Unsur

14) During the past 12 months, have you smoked cigarettes, cigars, pipes, or usedchewing tobacco?

Yes NoUnsure

Yes NoUnsure

Yes Unsur

15) Do you consume alcoholic beverages?

I Yes, please indicate Primary Applicant, Dep. 1 or Dep. 2 and the number oalcoholic beverages you consume weekly (a beverage is 12 ounces o beer, 6 ounces o

wine, 1 ounce o liquor):

Yes No

Unsure

___________

Yes No

Unsure

___________

Yes

Unsur

_________

16) During the past 5 years have you received counseling or been a member o a supportgroup related to personal alcohol or substance abuse?

Yes NoUnsure

Yes NoUnsure

Yes Unsur

17) During the past 5 years have you been convicted o driving under the infuence oalcohol or any controlled substance and as a consequence been required to receivecounseling or attend a support group or class related to driving under the infuence oalcohol or any controlled substance?

Yes NoUnsure

Yes NoUnsure

Yes Unsur

MALE APPLICANT(S) ONLY

18) Are you expecting a child with anyone, even i the mother is not listed on thisApplication? Yes NoUnsure Yes NoUnsure Yes Unsur

19) Has your spouse, even i not listed on this Application, perormed a home pregnancytest during the previous 90 days, which has indicated she was pregnant?

Yes NoUnsure

Yes NoUnsure

Yes Unsur






9/18

9IFPAPP12011-2 SAP 6022718 (



PrimaryApplicant

Dependent1

Dependent2

FEMALE APPLICANT(S) ONLY

20) Are you currently pregnant? Yes NoUnsure

Yes NoUnsure

Yes Unsure

21) During the previous 90 days, have you perormed a home pregnancy test whichindicated you were pregnant?

Yes NoUnsure

Yes NoUnsure

Yes Unsure

22) A. Have you had a menstrual period in each o the last six months, including withinthe last 30 days? I No, please indicate Primary Applicant, Dep. 1 or Dep. 2 andexplain: (attach additional pages as needed to provide complete inormation)

___________________________________________________________________

Yes NoUnsure

Yes NoUnsure

Yes Unsure

B. (i) Have you had a pelvic exam?I Yes, indicate Primary Applicant, Dep. 1 or Dep. 2 and list date o last pelvicexam (Mo/Dy/Yr): ____________________________________

Yes NoUnsure

Yes NoUnsure

Yes Unsure

(ii) Have you had a Pap smear?I Yes, indicate Primary Applicant, Dep. 1 or Dep. 2 and date o last Pap smear

(Mo/Dy/Yr): ____________________________________

Yes NoUnsure

Yes NoUnsure

Yes Unsure

(iii) Were the results o the exam(s) normal? I No, indicate Primary Applicant,Dep. 1 or Dep. 2 and please explain: (attach additional pages as needed to providecomplete inormation)

___________________________________________________________________

Yes NoUnsure

Yes NoUnsure

Yes Unsure

ALL APPLICANTS

Do you or any o the applicants have a Personal Health Record (PHR)? I Yes, pleaseinclude it with this application or mail it to Health Net, Post Oce Box 1150,Rancho Cordova, CA 95741-1150.

Yes No Yes No Yes




10/18

10PAPP12011-2 SAP 6022718 (1/1

Question#

IndicateApplicant

Diagnosis, condition, treatment orrecommendation

Still undertreatment?

Dates o treatmentor Hospitalization

(Mo/Yr)Began Ended

Full name, address and telephonenumber o every health care provider or

practitioner, clinic, hospital or any othermedical acility (include ZIP code)

Prim. App.Dep. 1Dep. 2

YesNo


YesNo


YesNo


YesNo

Date ovisit

IndicateApplicant

Reason or visit Result o visit Full name, address and telephonenumber o every health care provider orpractitioner, clinic, hospital or any othermedical acility (include ZIP code)





Condition IndicateApplicant

Name o Medication Prescribing Physician Most RecentRell Date

Strength(No. omilligrams)

Dosage and Frequency(How many pills andhow oten taken?)

Numbeo rellsper year



Part VII. (b) statement of health(continued) I you answered Yes to any questions in Part VII (A) (except questions 14, 15, 22(And 22(B)(iii)) please identiy the question number and explain in FULL DETAIL below. I additional space is necessary, please attach extra pages.

DoCtors VIsIts Please provide inormation regarding the last health care provider or practitioner visit or physical examination. additional space is necessary, please attach extra pages.

meDICatIons Please list all prescription medications you are currently taking. I additional space is necessary, please attach extra pages.





11/18

11IFPAPP12011-2 SAP 6022718

I, __________________________________________ was assisted in the completion o this Application by a qualied interpreter authorizeby Health Net because I:

Do not read the language o this Application. Do not speak the language o this Application. Do not write the language o this Applica

Other (explain): _____________________________________________________________________________________________

A qualied interpreter assisted me with the completion o: The entire Application. The Statement o Health.

Other (explain):

A qualied interpreter read this Application to me in the ollowing language:_________

SIGNATURE o APPLICANT Todays Date

Date Application was interpreted Time Application was interpreted

Qualied interpreter number

Part VIII. InDIVIDual & famIly Plans eXCePtIon to stanDarD enrollment statement of aCCountabIlIty

Instuctions o Pat VIII: The ollowing process is to be used when the Applicant cannot complete the Application because he or she cannotread, write and/or speak the language o the Application. Health Net requires that i you need assistance in completing this Application, you memploy the services o a qualied interpreter. Please contact Health Net at 1-800-909-3447, option 2 or inormation about qualied interpreteservices and how to obtain them. This orm must be submitted with the Individual & Family Enrollment Application when applicable.

Health Net Boe ID: ________________________________

Name (print): _________________________________________ Phone number: ________________________________________

Address: _____________________________________________ Fax number: ________________________________________

_____________________________________________ Email address:_________________________________________

____________________________________________________ ____________________________________________________Boe Sinatue/Numbe (requied) Date sined (requied)

Boe Cetifcation

I ____________________________________________________________________________________ (Name o Broker)

(NOTE: You must select the appopiate box. You may only select one box.)

(_____) did not assist the applicant(s) in any way in completing or submitting this application. All inormation was completed by theapplicant(s) with no assistance or advice o any kind rom me. I understand that, i any portion o this statement by me is alse, I may besubject to civil penalties, including but not limited to a ne o up to $10,000.Or(_____) assisted the applicant(s) in submitting this application. All inormation in the health questionnaire(s) was completed by theapplicant(s). I advised the applicant(s) that he or she should answer all questions completely and truthully and that no inormation reques

on the application should be withheld. I explained that withholding inormation could result in rescission or cancellation o coverage inthe uture. The applicant(s) indicated to me that he or she understood these instructions and warnings. To the best o my knowledge, theinormation on the application is complete and accurate. I understand that, i any portion o this statement by me is alse, I may be subjectcivil penalties, including but not limited to a ne o up to $10,000.

Please answe all questions 1 thouh 4:1)Who flled out and completed the application om? ______________________________________________________________

2) Did you personally witness the applicant(s) sign the application? Yes No

3) Did you review the application ater the applicant(s) signed it? Yes No

4) Are you aware o any inormation, including but not limited to medical history, not disclosed in this application, that might have a bearion the risk? Yes No

I Yes, please explain: _________________________________________________________________________________________

Part IX. agent/broker InformatIon Complete agent/broker name and address is necessary orcorrespondence to be sent to the agent/broker.

Instuctions o Pat IX: The ollowing orm is to be completed by the agent/broker (i applicable).



W W 617Health Covearge Insurance Services

Po Box 9417Santa Rosa, CA 95405

(707)509-0106

(800)376-4703

dennisa healthnetworkinsurance.co


@


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12FPAPP12011-2 SAP 6022718 (1/

GENERAL CONDITIONS: Health Net reserves the right to reject any Application or enrollment. Health Net may selectively accept the

Applicant or only a dependent(s). Children under age 19 are eligible to enroll in an Individual and Family Health Insurance Plan during certai

nrollment periods and cannot be declined due to a pre-existing medical condition as described in Section IV Special Enrollment or Children

under 19 Years o Age. There is no coverage unless this Application is accepted by Health Nets Underwriting Department and a Notice o

Acceptance is issued to the Applicant even though you paid money to Health Net or the rst months premium. Cashing your check does

not mean your Application is approved. I rejected, your money will be returned to you. No other department, ocer, agent or employee o

Health Net is authorized to grant enrollment. The Applicants broker or agent cannot grant approval, change terms or waive requirements o thi

Application. Health Net may require that you take a medical examination and you will be responsible or payment o any related ees in such

vent. This Application and all medical inormation or examination reports shall become a part o the Insurance Policy.

Family Members who are covered under another Health Net Individual plan are not eligible or coverage hereunder. Should a Family Member

nrolling or coverage become covered under another Health Net Individual plan at a later date, his or her coverage under this plan will terminat

on the eective date o coverage under the other Health Net Individual plan.

For applicants age 19 and older, to determine whether or not you will be oered enrollment in an individual insurance plan, Health Net

Lie Insurance Company (Health Net) will review your medical history based on the inormation you provide in this application, includi

he Statement o Health and any supplemental health questionnaires requested by Health Net during its review o your medical history. Th

process is called medical underwriting. Should you have questions or need assistance completing this application, especially the Statement

o Health, you can call Health Net at 1-800-909-3447 or assistance. I any health inormation changes ater you submit the application

o Health Net, but beore enrollment is oered, you should contact Health Net prior to any possible eective date o coverage at

-800-909-3447 to provide that new health inormation.

rESCISSION O MEMBErSHIP Or HEALTH NET LIE INSUrANCE COMPANY INDIVIDUAL PPO PLANS: Health Net

Lie Insuance Company (HNL) is an Insuance Company licensed and eulated unde the Calionia Insuance Code. HNL

undewites Individual PPO health insuance plans. Any audulent o willul nondisclosue o misepesentation o mateial acts

n witten inomation submitted by you o on you behal on o with you Application mateials may be cause o disenollment

and escission o the Insuance Policy and HNL may ecoup om the Policyholde (o om You o om the applicant) any amoun

paid unde the Insuance Policy obtained as a esult o such audulent o willul nondisclosue o misepesentation o mateial

acts. In addition, i a Policyholde maes any audulent o willul nondisclosue o misepesentation o mateial acts in witten

nomation submitted on o with the Application as to the Policyholdes o amily Membes health status o histoy, HNLhall have no liability o the povision o coveae unde the Insuance Policy. By sinin this Application, you epesent that all

esponses to the Statement o Health ae tue, complete and accuate and that should you Application be accepted by HNL, the

Application will become pat o the contact between HNL and yousel. By sinin this Application you uthe epesent and ae

o abide by the tems o the contact. Beoe the contact is escinded HNL will povide you witten notice and an oppotunity to

povide inomation. Should the contact be escinded, HNL will povide a witten notice that will explain the basis o the decision

and you appeals ihts. HNL will eund all amounts paid by you, less any medical expenses that HNL paid.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION: I acknowledge and understand that health care providers ma

disclose health inormation about me or my dependents to Health Net. Health Net uses and may disclose this inormation or purposes

o treatment, payment and health plan operations, including but not limited to, utilization management, quality improvement, disease

or case management programs. Health Nets Notice o Privacy Practices is included in the Insurance Policy, and that I may also obtain a

opy o this Notice on the website at www.healthnet.com or through the Health Net Customer Contact Center. Authorization or use and

disclosure o protected health inormation shall be valid or a period o 24 months rom the date o my signature below.

F SOLE APPLICANT IS A MINOR: I the sole Applicant under this Application is under 18 years o age, the Applicants parent or

egal guardian must sign as such. By signing, he or she does hereby agree to be legally responsible or the accuracy o inormation in this

Application and or payments o premiums. I such responsible party is not the natural parent o the Applicant, copies o the court papers

uthorizing guardianship must be submitted with this Application.

F APPLICANT CANNOT READ THE LANGUAGE OF THIS APPLICATION: I an Applicant does not read the language o

his Application and an interpreter assisted with the completion o the Application, the Applicant must sign and submit the Statement

o Accountability(see PART VIII o this Application, Individual & Family Plans Exception to Standard Enrollment Statement o

Accountability).

Part X. ConDItIons of enrollment





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13IFPAPP12011-2 SAP 6022718 (

APPLICANT OR PARENT OR LEGAL GUARDIANS SIGNATURE IF APPLICANT IS UNDER 18 YEARS OLD Date Signed

SPOUSE/DOMESTIC PARTNERS SIGNATURE Date Signed

SIGNATURE OF APPLICANTS DEPENDENT (age 18 or older) Date Signed

SIGNATURE OF APPLICANTS DEPENDENT (age 18 or older) Date Signed

The Application and this Abitation Clause must be sined by the Applicant. The Applicant must pesonally sin his o he name in and aee to comply with the Abitation Clause and the tems, conditions and povisions o the Application and the InsuancePolicy in ode o this Application to be pocessed. o this Application to be consideed, neithe Boe no any othe peson maysin this Application and Abitation Clause.

Mae pesonal chec payable to Health Net. retun Completed Application to:Health Net Individual & amily Enollment, Post Ofce Box 1150, rancho Codova, Calionia 957411150

You may submit a photocopy or acsimile o the Application and Authorizations. Health Net recommends that you retain a copy o thiApplication and Authorizations or your records.

All eeences to Health Net heein include the afliates and subsidiaies o Health Net which undewite o administe the coveawhich this Enollment Application applies. Insurance Policy reers to Health Net Lie Insurance Company Explanation

o Your Insurance Plan, Health Net PPO Policy.

NOTICE: For your protection, Caliornia law requires the ollowing to appear on this orm. Any person who knowingly presents a alsraudulent claim or the payment o a loss is guilty o a crime and may be subject to nes and connement in state prison.

HIV TESTINg PrOHIBITED:Calionia law pohibits an HIV test om bein equied o used by health cae sevices plans insuance companies as a condition o obtainin coveae.

ACkNOWLEDgEMENT AND AgrEEMENT: I, the Applicant, understand and agree that by enrolling with or accepting services rHealth Net, I and any enrolled dependents shall comply with the terms, conditions and provisions o the Insurance Policy. I, the Applihave read and understand the terms o this Application and my signature below indicates that the inormation entered in this Applicatiis complete, true and correct, and I accept these terms.

BINDINg ArBITrATION: I, the Applicant, undestand and aee that any and all disputes o disaeemenbetween me (includin any o my enolled amily membes o heis o pesonal epesentatives) and Health Neadin the constuction, intepetation, peomance o beach o the Health Net Insuance Policy, oeadin othe mattes elatin to o aisin out o my Health Net membeship, whethe stated in tot, contao othewise, and whethe o not othe paties such as health cae povides, o thei aents o employees, aealso involved, must be submitted to fnal and bindin abitation in lieu o a juy o cout tial. I undestandthat, by aeein to submit all disputes to fnal and bindin abitation, all paties, includin Health Net, aeivin up thei constitutional iht to the extent pemitted by law to have thei dispute decided in a cout olaw beoe a juy. I also undestand that disputes that I may have with Health Net involvin claims o medicmalpactice (that is, whethe any medical sevices endeed wee unnecessay o unauthoized o wee impopneliently o incompetently endeed) ae also subject to fnal and bindin abitation. A moe detailedabitation povision is included in the Insuance Policy. My sinatue below indicates that I undestand thetems o this Bindin Abitation Clause and aee to submit disputes to bindin abitation.

Part XI. ImPortant ProVIsIons





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14IFPAPP12011-2 SAP 6022718 (

As a convenience, I request and authorize Health Net to pay and charge to the above account checks drawn on that account by and payable to the order oHealth Net provided there are sucient collected unds in said account to pay the same upon presentation. I understand that the Premium withdrawn rommy account will be or the uture bill period plus any past due balances and my rst months withdraw may be or multiple periods i I did not submit a checkor due to the timing o the set up. I agree that Health Nets rights in respect to each such check shall be the same as i it were a check written to Health Netand signed personally by me. This authority is to remain in eect until revoked by me in writing and until Health Net actually receives such notice, I agreehat Health Net shall be ully protected in honoring any such check. (Note: A 30-day notice is required to discontinue this service due to the time required tonitiate this change with your bank.)

Automatic Bank Drat (ABD) transmissions are withdrawn rom your bank approximately the 20th o every month, or the ollowing months premium. It canake upwards o 6 weeks to process an ABD request. Thereore, your premium should be submitted with your request or ABD.

urther agree that i any such check be dishonored, whether with or without cause and whether intentionally or inadvertently, I will be charged a $25 service chargor each occurrence. I understand Health Net shall be under no liability whatsoever even though such dishonor may result in the oreiture o health coverage.

health nets Pay oPtIon monthly automatIC Payment for InDIVIDual & famIly Plans anD

CalIfornIa farm bureau members health InsuranCe Plan


The ZIP code must match the cardholders address otherwise the credit card cannot be processed.

As a convenience, I request and authorize Health Net Lie Insurance Company (Health Net) to charge my credit card account identied above or the paymento my initial premium and/or my monthly premium. I understand that the Premium charged to my account will be or the uture bill period plus any past duebalances and that my rst months withdraw / charge may be or multiple periods depending upon date o approval and the bill period. This authority is toremain in eect until revoked by me in writing and until Health Net actually receives such notice, I agree that Health Net shall be ully protected in honoring anysuch charge. (Note: A 30-day notice is required to discontinue this service due to the time required to initiate this change with your credit card company.) I urther agree that i my credit card is declined or payment, whether with or without cause and whether intentionally or inadvertently, I will be chaed a $25sevice chae o each occuence. Cedit cad account will be chaed appoximately the 20th o evey month, o the ollowin months pemium.

sImPle Payment oPtIon (aic b D)

First months payment Account type: Checking Savings

Transit Routing Number (9-digits) Account Number

Bank Name State

Ongoing monthly premium payment Same as above. Account type: Checking SavingsThe premium will be withdrawn rom your bank account about ten days in advance o the due date.

Transit Routing Number (9-digits) Account Number

Bank Name State

Signature o Account Holder (For First Months Payment) (Required to Process) Date

Signature o Account Holder (For Ongoing Monthly Payment) (Required to Process) Date

CreDIt CarD

First months payment You cad will be chaed o the fst months pemium on the day you Application is appoved by undewitin.

First Name (as on card) Middle (as on card) Last Name (as on card) Card Type Visa

MastercardAccount Number 16-digits (complete) Expiration Date (MM/YYYY)

Billing Address City State ZIP1

Ongoing monthly premium payment Same as above.Ongoing monthly premium charge can be charged directly to your credit card. The premium will be charged to your credit card accountapproximately ten days in advance o the due date.

First Name (as on card) Middle (as on card) Last Name (as on card) Card Type VisaMastercard

Account Number 16-digits (complete) Expiration Date (MM/YYYY)

Billing Address City State ZIP1

Signature o Credit Card Account Holder (For First Months Payment) (Required to Process) Date

Signature o Credit Card Account Holder (For Ongoing Monthly Payment) (Required to Process) Date


15/18

15IFPAPP12011-2 SAP 6022718 (


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16IFPAPP12011-2 SAP 6022718 (

- -

- -


17/18

Please detach and keep this copy for your records.

Information regarding your insurability will be treated as confidential. Health Net or its reinsurers

may, however, make a brief report thereon to the MIB, Inc., formerly known as Medical

Information Bureau, a not-for-profit membership organization of insurance companies, which

operates an information exchange on behalf of its members. If you apply to another MIB member

company for life or health insurance coverage, or a claim for benefits is submitted to such acompany, MIB, upon your request, will supply such company with the information about you

in its file.

Upon receipt of a request from you, MIB will arrange disclosure of any information in your file.

Please contact MIB at 1-866-692-6901 (TTY 1-866-346-3642). If you question the accuracy of

the information in MIBs file, you may contact MIB and seek a correction in accordance with the

procedures set forth in the federal Fair Credit Reporting Act. The address of MIBs information

office is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734.

Health Net, or its reinsurers, may also release information from its file to other insurance

companies to whom you may apply for life or health insurance, or to whom a claim for benefits

may be submitted. Information for consumers about MIB may be obtained on its website at

www.mib.com.

AuthorizAtion for use or disclosureof informAtion for enrollment

6022697_CA72710 (1/11AUTHENROLL0111

All references to Health Net herein include the affiliates and subsidiaries of Health Net, Inc. which underwrite or administer the coverage to which theEnrollment Application applies.

This authorization for use or disclosure of personal health information is being requested by Health Net to comply with the terms of federal HIPAA regulations,

45 C.F.R. 164.508.

Health Net Life Insurance Company and Health Net of California, Inc. are subsidiaries of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc.All rights reserved.


18/18

AuthorizAtion for use or disclosure

of informAtion for enrollmentBy signing below,

1. I authorize the ollowing to disclose medical inormation to Health Net: Any medical proessional, hospital, or other health care acility,clinic, pharmacy, insurer or health beneft plan administrator, MIB, Inc., (MIB), or any other health care provider or health plan thathas medical inormation, to include diagnosis, treatment or prognosis with respect to any physical, accident, illness, medical or mentalcondition, including but not limited to, alcohol or substance abuse, mental or emotional disorders, AIDS (Acquired Immune Defciency

Syndrome), or ARC (AIDS Related Complex), about me or my dependent(s); health care providers or health plans indicated in myapplication or coverage or on my dependents applications or coverage, or identifed by me during a health history interview in regard tmysel or my dependent(s), or identifed by me or my dependent(s) to my agent, or any other health care provider or health plan reerredto in my medical records or my dependents(s) medical records.

Inormation regarding your insurability will be treated as confdential. Health Net or its reinsurers may, however, make a brie reportthereon to the MIB, Inc., ormerly known as Medical Inormation Bureau, a not-or-proft membership organization o insurancecompanies, which operates an inormation exchange on behal o its members. I you apply to another MIB member company or lie orhealth insurance coverage, or a claim or benefts is submitted to such a company, MIB, upon request, will supply such company with thinormation about you in its fle. Upon receipt o a request rom you, MIB will arrange disclosure o any inormation in your fle. Pleasecontact MIB at 1-866-692-6901 (TTY 1-866-346-3642). I you question the accuracy o the inormation in MIBs fle, you may contactMIB and seek a correction in accordance with the procedures set orth in the ederal Fair Credit Reporting Act. The address o MIBsinormation ofce is 50 Braintree Hill Park, Suite 400, Braintree, Massachusetts 02184-8734. Inormation or consumers about MIBmay be obtained on its website at www.mib.com.

I also authorize Health Net, and its reinsurers, to release inormation rom their fle to other insurance companies to whom I may

apply or lie or health insurance, or to whom a claim or benefts may be submitted. Inormation or consumers about MIB maybe obtained on its website at www.mib.com.

2. I authorize the ollowing person(s) or group o persons to receive the inormation disclosed by one o the persons or organizations listedin paragraph one above, and to use that inormation and the inormation included on my application or coverage to underwrite andrate the health plan coverage or which I have applied: Health Net and its afliates including, but not limited to, its agents, underwritingoperations, including independent contractors who have executed Business Associate contracts to conduct underwriting activities onbehal o Health Net or do post enrollment review o any inormation or determination o whether a policy should be rescinded orintentional misrepresentation, o material acts, who have agreed to saeguard protected health inormation rom unauthorized use ordisclosure.

3. I understand that the inormation disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient, in which caseit may no longer be protected by ederal Privacy Rules governing the privacy o health inormation.

4. I understand that my or my dependents(s) enrollment in Health Nets health plan may be conditioned on signing this Authorization.As described in the Notice o Privacy Practices, I understand that I may revoke this Authorization in writing at any time, except to the

extent that action has been taken by Health Net or its Business Associates in reliance on this Authorization. I may send a written anddated revocation to Health Net at the address below. This Authorization will become eective immediately and shall remain valid orthirty (30) months rom the date the authorization orm is signed, except that, or Caliornia residents, this Authorization will remain ineect or one year rom the date o the Authorization.

5. I the person completing this Authorization is the personal representative o the applicant or dependent, describe your authority toact on this persons behal:_____________________________________________________________________________________

__________________________________________________________________________________________________________

A photocopy of this form is as valid as the original. You have the right to receive a copy of this Authorization upon request.

Signatures (required in ink):

______________________________ ____________________________________________ ____________

Printed name o Applicant Signature o Applicant or his or her Personal Representative Date

______________________________ ____________________________________________ _____________Printed name o spouse or dependent Signature o spouse or dependent child (age 18 or older) Datechild (age 18 or older) or his or her Personal Representative

This authorization or use or disclosure o personal health inormation is being requested by Health Net to comply with the terms o ederal HIPAA regulations, 45 C.F.R. 164.508.

______________________________ ____________________________________________ _____________Printed name o dependent child Signature o dependent child (age 18 or older) Date(age 18 or older) or his or her Personal Representative

PLEASE RETURN THIS FORM TO: Health Net Individual & Family Plans, PO Box 1150, Rancho Cordova, CA 95741-1150

health net california individual family application (fillable) 2011

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