You agree your electronic signature is the legal equivalent of your manual signature on this ... 2021 coverage, the Annual Open Enrollment Period runs from.
Nongroup Enrollment/Change Request Florida Off-Exchange Choose your plan [ ] Oscar Bronze Classic [ ] Oscar Bronze Classic Next [ ] Oscar Bronze Classic Next 2 [ ] Oscar Bronze HDHP [ ] Oscar Bronze Simple [ ] Oscar Silver - $1,500 Ded [ ] Oscar Silver Classic [ ] Oscar Silver Classic - $0 Ded [ ] Oscar Silver Classic Copay [ ] Oscar Silver Classic Next [ ] Oscar Silver HDHP[ ] Oscar [ ] Oscar Silver Saver [ ] Oscar Silver Saver 2 [ ] Oscar Silver Virtual Care [ ] Oscar Gold Classic [ ] Oscar Secure Note: Pediatric Dental coverage is included in all medical plans Oscar ID (if changing an existing plan) Who are you buying insurance for? [ ] Individual [ ] Individual & Spouse Type of Activity [ ] Parent & Child(ren) [ ] Family [ ] Child Only [ ] Add dependent [ ] Remove dependent [ ] New enrollment [ ] Change benefit plan [ ] Update name [ ] Marital status change and/or address Special enrollm ent period (following a triggering event, see list in instructions) Req u est ed Start Date _____/_____/_________ Date of QLE _____/ _____/ _________ Qualifying life event (if applicable) Who?s Covered Name (First, Middle Initial, Last) Applicant Spouse Child d ep en d en t (s) Is dependent Sex disabled?* (M/F) Social Security No. Date of Birth (M M / DD/ YYYY) Phone number Em ail Eligible for Medicare? Smoker?* * * If you have a disabled dependent over age 26, please contact us at brokers@hioscar.com to request a disabled dependent form * * Within the past 6 months have you used any tobacco products 4 or more times per week, on average, excluding religious or ceremonial use? Tobacco products include products such as cigarettes, e-cigarettes, cigars, chewing tobacco, snuff, pipe tobacco, and others. Note that when determining your premium, Oscar may consider whether you smoke or use tobacco. Answer required for ages 19+. Just a few more questions Home address (P.O. box does not qualify) Apt # Cit y Co u n t y St at e Zip code Home phone Cell phone Email address Primary language (if other than English) If your mailing address is different than your home address, please enter it below Marital status Single M ar r ied Domestic Partner Nam e Address Apt # Cit y Co u n t y St at e Zip code Do you maintain a home in another state or county? Yes No Have you ever tested positive for exposure to HIV or been diagnosed as having ARC or AIDS? Yes No GA / Broker info (if applicable) Nam e GA National Producer Number (NPN) Broker Co-broker Agency name Phone Em ail Florida License Identification Number Please Read the Following Terms & Conditions Carefully I u n der st an d t h at u pon r eview of m y Con t r act t h at I m ay can cel it . An y r equ est t o can cel m u st be m ade in w r it in g w it h in 14 days f r om t h e dat e I r eceive t h e Con t r act . On beh alf of m yself an d an y cover ed depen den t s, t o t h e ext en t per m it t ed by law , I h er eby au t h or ize all h ealt h car e pr ovider s w h o h ave r en der ed ser vice t o an y of u s an d an y payer s of claim s t o pr ovide t o Oscar an y r ecor ds per t ain in g t o car e pr ovided, claim s paid an d/ or ou r m edical h ist or y. I au t h or ize Oscar t o pr ovide su ch in f or m at ion t o n et w or k ph ysician s f or t h e pu r pose of con t in u it y of car e, m edical m an agem en t , et c. An y per son w h o k n ow in gly an d w it h in t en t t o in ju r e, def r au d, or deceive an y in su r er f iles a st at em en t of claim or an applicat ion con t ain in g an y f alse, in com plet e, or m isleadin g in f or m at ion is gu ilt y of a f elon y of t h e t h ir d degr ee. I am applyin g f or cover age f or m yself , m y spou se an d m y eligible depen den t ch ildr en n am ed on t h is applicat ion . All st at em en t s m ade w it h in t h is f or m ar e t r u e an d accu r at e t o t h e best of m y k n ow ledge. Sign at u r e Dat e By typing your name, you are signing this Agreement electronically and consenting to its terms & conditions. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. Note that Oscar will use either your qualifying event date or date the application was submitted to Oscar to determine your effective date of coverage. We will not use the signature date on this application. O SC-FL-IVL-APP-2021 In st r u ct io n s - With the exception of the last question, you must complete all sections, and sign and date this form. - Please print except when a signature is requested. - If a dependent child is disabled and you want to continue his or her coverage beyond age 26, attach proof of disability and contact Oscar for a Disabled Dependent form. - If you are applying to add a spouse, civil union partner, domestic partner, or child outside of Open Enrollment please check ?Add dependent?in the ?Type of Activity?section and identify the applicable Qualifying Life Event. - Eligible for Medicare means the person satisfies the requirements for Medicare but has not yet enrolled in Medicare. Entitled or Enrolled under Medicare parts A or B means you have Medicare and CANNOT enroll in an individual plan. - If you have any questions concerning the benefits or services provided by or excluded under this policy, contact a customer service representative by navigating to ?Get help?on hioscar.com or emailing help@hioscar.com before signing this form. - Keep a copy of this completed application! - You can print out a temporary ID card on hioscar.com if needed. Coverage must be verified with Oscar prior to visiting with a specialist or admission to a hospital. Qualifying Life Events include, but are not limited to: 1. Involuntary loss of minimum essential coverage 2. Dependent attained age 26 and lost coverage 3. Marketplace changed your subsidy determination 4. Change in household due to marriage, domestic partnership, birth, adoption or placement for adoption, placement in foster care or a child support order or other court order 5. Gained access to plans as a result of permanent move to a new st at e 6. No longer incarcerated 7. Became lawfully present 8. Holds or gained status as an Native American or Alaska Native For a list of Qualifying Life Event documentation, please see h ioscar .com / b r oker s Eligib ilit y - You must not be enrolled in or entitled to Medicare Parts A or B. - If application is made for the Secure Plan the following additional requirements apply: 1. You must be under 30 years old at the beginning of the plan year; OR 2. You must have a Certificate of Hardship Exemption from the Marketplace. Attach a copy to your application. - The Annual Open Enrollment Period is the designated period of time each year during which you may apply for, or change coverage for, yourself and your dependents. Your application must be received during the designated Annual Open Enrollment Period, unless you?ve experienced a Qualifying Life Event. For 2021 coverage, the Annual Open Enrollment Period runs from November 1st, 2020 through December 15th, 2020. - A Special Enrollment Period lasts for 60 days following a Qualifying Life Event. In certain cases, the applicant may also apply during the 60 days leading up to the Qualifying Life Event. - Pediatric dental is a mandatory Essential Health Benefit under the Affordable Care Act (ACA) and is included in all plans. Benefits are provided to any covered person under the age of 19. - Note: If you currently have coverage, and the plan for which you are applying will replace the current coverage, you should not terminate your current policy until the new coverage is active. O SC-FL-IVL-APP-2021Zeeshan Dawdani