Elevate Health Plans Off Exchange Enrollment Form
Federal financial assistance may be available for coverage purchased through Connect for Health Colorado. If purchasing coverage through Connect for Health Colorado, you will need to provide additional information for determination of eligibility for federal financial assistance. Further information may be found at www.connectforhealthco.com
By submitting this Enrollment Form you are purchasing an Elevate Health Plan. Be sure to confirm your estimated monthly premium before submitting this Enrollment Form. For questions, call us at 303-602-2090 Monday – Friday 8 a.m. to 5 p.m.
Application Type: New Coverage Change/Modification to Existing Coverage Open Enrollment Special Enrollment Period (Proof of Special Enrollment eligibility is required)
Bronze HDHPBronze StandardSilver SelectSilver StandardGold SelectGold StandardNo Plan Selected Requested Effective Date: MM010203040506070809101112 / / Coverage begins on the first day of the month, except in the cases of birth or adoption.
Instructions: please fill out the entire application for each person for whom coverage is being sought. If a person is currently enrolled in Medicare, this application should not be completed for that enrolled individual. If additional pages are needed to fully complete this application, please add the information to the DISCLOSURES section at the end of this application.
Complete ONLY if your spouse/partner, and/or child(ren) under the age of 26 (older if medically disabled) are applying for coverage. If additional pages are needed to fully complete this application, please add the information to the DISCLOSURES section at the end of this application.
Please answer the following questions to the best of your knowledge. 45 CFR 147.102(a)(1)(iv) "For purposes of this section, tobacco use means use of tobacco on average four or more times per week within no longer than the past 6 months. This includes all tobacco products, except that tobacco use does not include religious or ceremonial use of tobacco. Further, tobacco use must be defined in terms of when a tobacco product was last used."
Has anyone named in this application used tobacco or smokeless tobacco during the past 6 months? If yes, how many? 123456
I acknowledge that I have read all sections of this Enrollment Form, and I certify on behalf of my eligible family dependents and myself that the answers contained in this Enrollment Form are complete and accurate to the best of my knowledge.
I understand that my answers, together with any supplements or additional pages, are the basis for the certificate or policy that is issued. I agree that no insurance will be effective until the date specified by the carrier on the certificate or policy.
I understand that my signature constitutes an attestation that I have obtained the required pediatric dental coverage under a separate policy, and may be required to provide proof of this pediatric dental policy prior to this policy being issued and approved. (Certification of dental insurance coverage is not required when purchasing coverage through Connect for Health Colorado)
I understand that any intentional misrepresentation relied upon by the carrier may be used to deny a claim. I further understand that this contract can be voided if, within the first 24 months from the date of the policy or certificate, it is determined that I or a family member made an intentional misrepresentation in this Enrollment Form.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance carrier for the purpose of defrauding or attempting to defraud the carrier. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance carrier or agent of an insurance carrier 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 Colorado Division of Insurance within the Department of Regulatory Agencies.
I understand that I may request a copy of this Enrollment Form. I agree that a photographic copy of this Enrollment Form shall be as valid as the original. A legible facsimile signature shall have the same force and effectiveness as the original. This document, or the information contained herein, will become a part of the contract when coverage is approved and issued.
I would like to receive all policy notices, premium notices, and other notices relating to this policy through the supplied email address above. Yes No
I understand I can change this designation at a later date by contacting my carrier directly, and understand it is my responsibility to notify my carrier of any changes to my mailing address and contact information, including phone number and email address.
If you have questions about the content of this document please contact the office of the Colorado Division of Insurance at 303-894-7499 or visit the website at http://www.dora.colorado.gov/insurance.
For questions regarding coverage or enrollment please contact Elevate Health Plans at 303-602-2090.
This section may be used to provide additional information that was required in the sections above and did not fit in the space provided.