IMPORTANT Please read the following before signing this enrollment form. If elected, my employer and I agree that my taxable income will be reduced each pay period during the year by an equal portion of the benefits elections set forth above and that qualified expenses will be paid on a tax-savings basis. I understand that I may change my election in the event of certain changes in my status and that prior to the first day of each plan year I will be offered the opportunity to change my benefit election for the upcoming plan year. I acknowledge that I have received, read, and understand Summary Plan Description. I understand that the take care® Card is available to pay only qualified expenses which can then not be reimbursed by any other plan and that I will not seek reimbursement for expenses paid with the Card from any other source. I understand that when using the take care Card, I must keep all receipts and that on occasion I may be asked for documentation of charges made with my card. I also understand that if a payment is made that is not for a qualified expense I will repay my employer. For any expenses not repaid by me, I authorize my employer to deduct the amount from my paycheck (if permitted by state law).
I understand that the benefits for which I (we) will be eligible are in accordance with those described in the Master Group Contract and any attached riders.
I hereby consent to the release of any medical, health and/or payment information (including without limitation pharmacy and claims information) about me and my minor eligible dependents by any licensed physician, hospital, other health care provider, or authorized federal, state or local agencies to the insurance carrier or any health care providers involved in caring for me or my minor eligible dependents, as reasonably necessary to allow the insurance carrier to administer my benefits or for the insurance carrier or my health care providers to carry out treatment, payment, or health care operations functions, to the extent permitted by law. I also agree that the information released for treatment, payment and health care operations may include HIV, STD, mental health or alcohol and substance abuse information about me and my minor eligible dependents to the extent permitted by law, until I revoke this consent. I hereby certify that the statements made are true and complete to the best of my knowledge and belief.
I have read and agree to the authorization on this form. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
