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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.

PLAN SELECTION


Application Type:  New Coverage    Change/Modification to Existing Coverage   Open Enrollment    Special Enrollment Period (Proof of Special Enrollment eligibility is required)


Requested Effective Date:  /  Coverage begins on the first day of the month, except in the cases of birth or adoption.
 

PRIMARY APPLICANT/INSURED INFORMATION

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.



First Name: Middle Initial (optional): 

Last Name: 

Social Security #: Date of Birth: / /  Current Age: 

Sex: M F

Physical Address: City: County:

State:   Zip:  

Mailing Address (if different than physical address): City:  County: 

State:   Zip:  

Phone: Alternate Phone:

E-mail:

Language Preferred:

Are you:    
*A common law, civil union or designated beneficiary certification may be required by the carrier.

Are you, or is anyone in your family American Indian or Alaskan Native? 

Employer Name:  Employer Address: 

Work Phone: 
 
Add Spouse/Partner? Yes  No

Add Dependents?

Social Security Numbers (or document numbers for any legal immigrants) are needed for anyone applying for health insurance, missing numbers will be requested after enrollment.
 
TOBACCO USE

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? 

 
MEDICARE/MEDICAID INFORMATION

Is any applicant enrolled in Medicare?  

If so, how many 
Is any applicant enrolled in Medicaid, CHP+, or other governmental health program?  

If so, how many 
 
CURRENT MEDICAL COVERAGE

Do you, your spouse/partner, or your dependent child(ren) listed in this application currently have health insurance?   
(Dental Coverage in Next Section)

How many listed in this application currently have health insurance? 
 

If any applicant has current health coverage, will that applicant cancel current coverage if this applicant is accepted?  

Type of Coverage Key:
G = Group Comprehensive Major Medical; I = Individual Comprehensive Major Medical; MS = Medicare Supplement; H = Hospital Coverage Only; V = Vision Coverage Only; O = Other, please explain: 
 
CERTIFICATION OF DENTAL INSURANCE COVERAGE
(Certification of dental insurance coverage is not required when purchasing coverage through Connect for Health Colorado)

Pediatric dental coverage is a required essential health benefit. This plan does not include pediatric dental coverage. Do you have pediatric dental coverage under another plan?



Note: you may be required to provide proof that you have obtained coverage before this policy will be approved
 
TERMS AND CONDITIONS


 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.
 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.

SIGNATURE

I have read, understand and agree to all provisions set forth in this application.
I understand that I'm required to provide true answers.
 I have calculated my estimated monthly premium.
 
 I understand that I will be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period. If I don't, I may face the risk of losing my eligibility for coverage.

Please type your full name in the space below to electronically sign your application.

Signature of Primary Applicant/Parent or Legal Guardian for Child-Only Plans:  

Date Signed: 
 
 
Complete this section if someone assisted you in the completion of this Application

The following person assisted me in completing the Application:  

Please explain the assistant’s relationship to you and your family:  
 
AGENT/PRODUCER
 
This application was prepared by an Agent/Producer.
 
This section is to be completed by Agent or Producer.

Name of Agent / Agency of Record (for commissions and correspondence):  Agent ID# (NPR):

Name of Writing Agent / Producer: Agent ID# (NPR):  

E-mail:

Appointment Writing Number: 

Agent replacement question: Will this policy replace any existing accident and sickness insurance policy(s)?  

As the Writing Agent/Producer, I acknowledge that I am responsible to personally interact with the primary applicant submitting this application in order to fully and accurately represent the terms and conditions of the plans and services of the offering or insuring entity, or one of its subsidiaries. These provisions are available to me and the primary applicant in the benefits summary document or other plan literature.

Writing Agent Signature: 

Date: 
 I understand that I will be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period. If I don't, I may face the risk of losing my eligibility for coverage.
DISCLOSURES


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.


Please type your full name in the space below to electronically sign the disclosures section:

Signature of Primary Applicant/Parent or Legal Guardian for Child-Only Plans:  

Date Signed: 


Important: Please do not close this window or tab until you see a confirmation page. That page will ensure that your application has been submitted.

A confirmation email will be sent to the email address of the primary applicant. If primary applicant does not receive a confirmation email within 24 hours, please contact Elevate by DHMP at 303-602-2090.