If any payroll deductions are required for this coverage, I authorize such deductions from my earnings. I reserve the right to revoke this deduction authorization at any time upon written notice to the employer. An Application should not be submitted more than 45 days prior to the effective date. This document will become a part of the insurance contract when coverage is approved and issued.
I understand that I may request a copy of this Application and the Authorization to Use and Disclose Protected Health Information that are part of this Application. I agree that a photographic copy shall be as valid as the original. A legible facsimile signature shall have the same force and effectiveness as the original.
Signature of Employee: ___________________________________________ Date Signed: __________________
Signature of Spouse: _____________________________________________ Date Signed: __________________
Signature of each listed dependent who has attained the age of 18:
________________________________________ Date Signed: ___________ Print Name _______________________
________________________________________ Date Signed: ___________ Print Name _______________________
Complete this section if someone assisted you in the completion of this Application.
The following person assisted me in completing the Application: ____________________________________________
Please explain your relationship with the Applicant: ______________________________________________________
Instructions: Please read this authorization form carefully before signing. This form must be signed by each adult person seeking coverage, including all adult dependent children. Parents should sign for their minor children unless the minor has received treatment without parental consent, consistent with state law. Your application cannot be processed without a signature for each person seeking coverage. Signing this form is a condition of coverage: if you decide not to sign, you will not be enrolled in a health plan of the insurers listed below. You have the right to receive a copy of this form following your signature.
I. Protected Health Information
By signing this form, I authorize certain organizations and persons to use or disclose my, my spouse’s and my dependent child(ren)’s protected health information. Protected health information includes, but is not limited to, hospital records, physician records, lab results, mental health records, and alcohol and/or drug abuse records. Protected health information may be written, oral, or electronic. This form does not permit the use or disclosure of psychotherapy notes or the disclosure of information concerning whether I, my spouse or my dependent child(ren) have obtained a test for the presence of HIV antigen or nonantigenic products of HIV or an antibody to HIV or what the results of this test were.
II. Purpose of this Authorization Form
By signing this form, I, my spouse and my dependent child(ren) authorize the use and disclosure of protected health information for the purposes of pre-enrollment underwriting or risk-rating of health insurance coverage for me, my spouse and my dependent child(ren), to determine eligibility for enrollment or benefits under a health plan or to allow the insurer to conduct utilization review and quality improvement activities (“Purpose”).
III. Entities Authorized to Use and Disclose My Protected Health Information
Insurers: I hereby authorize the following insurers, their reinsurers, and their legal representatives (“Insurers”) to receive, use, and disclose my, my spouse’s and my dependent child(ren)’s protected health information for the Purpose listed above:
Insurer: _________________________________________ Insurer: ________________________________________
Insurer: _________________________________________ Insurer: ________________________________________
I authorize the Insurers to disclose my, my spouse’s and my dependent child(ren)’s protected health information: between themselves, to reinsuring companies, and to the plan administrator (if other than the employer), plan sponsor (if other than the employer), insurance intermediaries, or other persons or organizations performing business or legal services in connection with the Purpose above.
I further authorize any licensed physician, medical practitioner, health care provider, hospital, clinic, or other medical or medically related facility, insurance or reinsuring company, Medical Information Bureau, Inc., consumer reporting agency, or other organization, institution, or person that has any record or knowledge of me, my spouse or my dependent(s), to give to Insurers any and all protected health information about me, my spouse, or my dependent(s) to be covered concerning diagnosis, treatment and prognosis for any physical or mental condition, history or character, general reputation, personal trait, and mode of living, including, but not limited to, all medical and health care records, but not including whether I, my spouse or my dependent(s) obtained a test for the presence of HIV antigen or nonantigenic products of HIV or what the results of this test were.
I, my spouse and my dependent child(ren) understand that protected health information described in this form may be used by, or disclosed to or by, organizations and persons who are not subject to federal or state privacy laws.
IV. Term of Authorization
I agree this Authorization shall be valid for two and one half (2 ½) years from the latest signature date below.
V. Right to Revoke
I understand I, my spouse or my dependent child(ren) may revoke this authorization at any time by giving advance written notice to Insurers. Revocation of this authorization form will not affect actions Insurers and others took in reliance on this form prior to the written notice of revocation.
I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THIS FORM. I UNDERSTAND THAT, BY SIGNING THIS FORM, I AUTHORIZE THE USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION DESCRIBED IN THIS FORM. I UNDERSTAND THAT I MAY ONLY REVOKE AUTHORIZATION FOR MYSELF OR MY MINOR CHILD(REN) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW. (CONTINUED ON THE NEXT PAGE.)
_________________________________ ________________ _________________________________
Signature of Adult Applicant Date signed Printed Name
_________________________________ ________________ _________________________________
Signature of Spouse (if applicable) Date signed Printed Name
I have had full opportunity to read and consider this form. I understand that, by signing this form, I authorize the uses and disclosures of protected health information described in this form. I understand that I may only revoke authorization for myself or my minor child(ren) UNLESS MY MINOR CHILD(REN) HAS RECEIVED TREATMENT WITHOUT MY CONSENT, CONSISTENT WITH STATE LAW.
___________________________________ ________________ _________________________________
Signature of Adult Dependent Date signed Printed Name
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child(ren) (if applicable)
If signing for more than one child, please list the names of each child for whom you are signing:
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
_________________________________________ _________________________________________
Name of Minor Child (please print) Name of Minor Child (please print)
For services received by a minor that under state law the minor may consent to treatment without parental or legal guardian consent:
___________________________________ ________________ _________________________________
Signature of Parent or Legal Guardian Date signed Name of Minor Child (please print)
for Minor Child (if minor received
treatment with knowledge of parent)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
___________________________________ ________________ _________________________________
Signature of Minor Child (if minor may Date signed Name of Minor Child (please print)
have received treatment that does not require
parent or legal guardian authorization)
Uniform Employee Application
OCI 26-501 (R 6/2010)
Ins 8.50Ins 8.50 Underwriting restriction. In determining whether to issue or continue to provide coverage to a small employer, a small employer insurer may not consider the occupation of the employees of the small employer or the type of business in which the small employer is engaged. Ins 8.50 HistoryHistory: Cr. Register, October, 1992, No. 442, eff. 11-1-92. Ins 8.52Ins 8.52 Regulation of rates and rate changes. Ins 8.52(1)(1) Identification of the set of midpoint rates. Ins 8.52(1)(a)(a) Each small employer insurer shall identify a set of rates applicable to all combinations of case characteristics and benefit design characteristics that serves as the set of midpoint rates for policies issued to small employers. These rates shall be represented by any combination of rates and rating factors that satisfy the following: Ins 8.52(1)(a)1.1. All differences among rates in the set shall be in accordance with the insurer’s rate manual or rating procedures and shall be based on the actuarially determined values of the differences in case characteristics and benefit design characteristics. Ins 8.52(1)(a)2.2. The differences among the rates may not reflect any differences due to such factors as the claim experience, health status and duration of coverage of an individual policy or a collection of policies grouped according to anything other than case characteristics or benefit design. Ins 8.52(1)(b)(b) The set of midpoint rates identified in par. (a) shall apply during a specified period which shall not be less than one calendar month. Ins 8.52(2)(a)(a) For a new policy issued on or after March 15, 1992, the following table lists the maximum percent a rate may vary from the midpoint rate applicable to policies with the same case characteristics and benefit design characteristics according to the effective date of any rate applied to that policy: Ins 8.52(2)(b)(b) For a policy issued before March 15, 1992, an insurer shall comply with the rate variance restriction specified in par. (a) 2 no later than August 15, 1994. Ins 8.52(3)(3) Premium rate changes; documentation and restrictions. Ins 8.52(3)(a)(a) For the purpose of complying with s. 635.02 (2), Stats., and this subsection,“class of business” means a group of policies with the same or similar benefit design whose rates are based wholly or partly on their aggregate loss experience. Ins 8.52(3)(b)(b) For a policy renewed on or after March 15, 1993, an insurer shall maintain sufficient documentation so that each of the following distinct components can be identified: Ins 8.52(3)(b)1.1. The percentage change in the new business premium rate measured from the rating period in which the small employer was last rated to the current rating period or, in the case of a class of business for which the insurer is not issuing new policies, the corresponding change in the base premium rate. Ins 8.52(3)(b)2.2. The percentage change due to adjustments in case characteristics, determined in accordance with the insurer’s rate manual or rating procedures. Ins 8.52(3)(b)3.3. The percentage change due to adjustments in benefit design, determined in accordance with the insurer’s rate manual or rating procedures. Ins 8.52(3)(b)4.4. The percentage change due to such rating factors as claim experience, health status and duration of coverage, determined in accordance with the insurer’s rate manual or rating procedures. Ins 8.52(3)(c)(c) Each renewal rate, regardless of whether the rate represents an increase, shall be limited to the previous rate adjusted by the combination of the 4 components specified in par. (b) with the following restrictions on the experience component specified in par. (b) 4.: Ins 8.52(3)(c)1.1. For a policy issued on or after March 15, 1992, the experience component shall be limited to 15% per year, adjusted proportionately for rating periods of less than one year. Ins 8.52(3)(c)2.2. For a policy issued before March 15, 1992, subd. 1. applies, except if the premium rate exceeds the midpoint rate by more than the percentage specified in sub. (2) (a) for the applicable period for policies with the same case characteristics and benefit design characteristics, the experience component may not exceed 0%. Ins 8.52(3)(d)(d) For a rate change made before the end of the policy term due to the addition of a new entrant, late enrollee, underwritten individual or a new dependent of an insured employee, par. (c) applies, except that: Ins 8.52(3)(d)1.1. The new business rate change component specified in par. (b) 1. may not be applied at that time. Ins 8.52(3)(d)2.2. The experience component specified in par. (b) 4. may not exceed 15% per year, adjusted proportionately to the time remaining in the policy term. Ins 8.52(3)(d)3.3. The experience component specified in par. (b) 4., when combined with the experience component of the last scheduled rate renewal and any other subsequent rate changes during the current policy term, shall not exceed the limit specified in par. (c) 1. or 2., whichever applies. Ins 8.52(4)(a)(a) On or before December 1, every small employer insurer shall annually file with the commissioner the small employer insurer’s lowest available monthly new business premium rates which will be in effect the following January 1. The filing shall be made on a form provided by the commissioner and shall require all of the following information as may apply to the type of plan offered: Ins 8.52(4)(a)1.1. For an indemnity plan, the rates shall be based on the insurer’s plan that is closest to a plan that features a $500.00 annual deductible and 80%/20% coinsurance. Ins 8.52(4)(a)2.2. For a defined network plan, the rates shall be based on a plan which is actuarially equivalent to the features described in subd. 1. Ins 8.52(4)(a)3.3. For all plans, the rates shall be specified for family and single plans, by group size and by the geographical criteria that are used by the insurer. Ins 8.52(4)(a)4.4. The commissioner may require additional information be provided in the form as appropriate to implement this subsection. Ins 8.52 NoteNote: OCI 26-500, the form described in this subsection may be obtained without charge by contacting the Office of the Commissioner of Insurance PO Box 7873, Madison WI. 53707-7873. The form is also available on the OCI website at oci.wi.gov
Ins 8.52(4)(b)(b) Small employer insurers who file rates with the commissioner as described in this subsection will be in compliance with the requirements of s. 635.12, Stats. Ins 8.52 HistoryHistory: Cr. Register, October, 1992, No. 442, eff. 11-1-92; am. (3) (d) (intro.), Register, November, 1993, No. 455, eff. 2-1-94; CR 02-043: cr. (4), Register October 2002 No. 562, eff. 11-1-02. Ins 8.54Ins 8.54 Guaranteed renewability; cancellation and renewal restrictions. Ins 8.54(1)(a)(a) In this section, “medically underwritten policy” means a policy that is issued after the small employer insurer has, for purposes of risk selection, used information about the group’s claim experience or the health history or medical records of one or more persons eligible for coverage.
