Download trh health plans application

TRH HEALTH PLANS APPLICATION
PLEASE PRINT USING BLACK INK
Section 1
Primary Applicant Information
First Name
MI
Last Name
Mailing Address
City
State
Date of Birth
_
_
Age
Male
Female
Zip Code
Marital Status (Optional)
Single
Married
Widowed
Divorced
Yes
No
Phone No. (
) _______-_________
May we leave a message?
Yes
No
Alternate No. (
) _______-________
May we leave a message?
Yes
No
County
Email Address (if applicable):
Effective Date
Date of Marriage/Divorce
_
_
Tobacco Use:
Never
Currently use tobacco products
Previously used tobacco products but stopped on (DATE): ________
Height
Are you an existing TN Farm Bureau member? If “No”, please submit
a TN Farm Bureau Membership Application and Agreement.
TN Farm Bureau membership is in the name of: __________________
TN Farm Bureau membership number: _________________________
Section 2
OFFICE USE ONLY
Sub Group
Weight
Social Security No.
_
_
Rating Action
Primary Care Physician:
How did you hear about TRH?
Internet
TV
Phone Book
Radio
Mail Ad
Billboard
TN Farm Bureau
Family/Friend
Application Type
New Application for Coverage
Transfer From Other TRH Coverage. Current ID Number: ________________
Add a Dependent to Existing Family Coverage
Add a Dependent to Existing Individual Coverage and Change to Family Coverage
Reapplication - Current TRH subscriber re-applying for new coverage (Under 65 Acknowledgement required.). Current ID Number: ___________
Section 3
ID Number
Person
Rider(s) #
1. _______________
2. _______________
3. _______________
4. _______________
Person(s) Excluded
1. _______________
2. _______________
Coverage Options
The following coverage options contain at least a 12 month pre-existing
condition waiting period.
Complete Care - Deductible: $1500
Family (Maternity benefits after a member’s
coverage has been in effect for 9 consecutive months.)
Individual
(No maternity benefits)
The following coverage options contain at least a 6 month
pre-existing condition waiting period.
Core Choice - Deductible:
$1500
$3000
Individual
(No maternity benefits)
Family (Maternity benefits after a member’s coverage
has been in effect for 9 consecutive months.)
Major Medical - Deductible: $5000
Family (Maternity benefits after a member’s
coverage has been in effect for 9 consecutive months.)
Individual
(No maternity benefits)
Value Care - Deductible Options:
$600
$1200
$2000
Individual Only (No maternity benefits)
Premier - Deductible Options:
$500
$1000
$2500
Individual
Family (Maternity benefits after a member’s
(No maternity benefits)
coverage has been in effect for 9 consecutive months.)
High Deductible (HSA-Qualified)
(Individual/Self only - No maternity benefits)
(2 or 3-Person and Family - Maternity benefits after a member's coverage has
been in effect for 9 consecutive months)
Self Only - $1500 Deductible
3-Person - $5000 Deductible
Self Only - $2500 Deductible
Family - $3000 Deductible
2-Person - $5000 Deductible
Family - $5000 Deductible
Other ______________________________________________________
Section 4
The following coverage options are for children age 18 or under.
Options are individual only with no maternity benefits.
Premier Child Coverage –
(12 month pre-existing condition waiting period.)
Age:
0-2 years
3-7 years
8-18 years
Deductible Options:
$300
$500
$1000
Core Choice Child Coverage –
(6 month pre-existing condition waiting period.)
Deductible:
$1500
$3000
Spouse / Dependent Information
PLEASE COMPLETE ONLY IF YOUR SPOUSE AND/OR DEPENDENT CHILDREN ARE APPLYING FOR COVERAGE.
SPOUSE First Name
MI
Last Name
Gender
Date of Birth
Age
Social Security No.
M
F
Tobacco Use:
Never
Currently use tobacco products
Previously used tobacco products but stopped on (MM/YY): ________
DEPENDENT 1 First Name
Tobacco Use:
LG-FM13-216
Gender
M
F
MI
Last Name
Gender
M
F
Never
Currently use tobacco products
Previously used tobacco products but stopped on (MM/YY): ________
DEPENDENT 3 First Name
Tobacco Use:
Last Name
Never
Currently use tobacco products
Previously used tobacco products but stopped on (MM/YY): ________
DEPENDENT 2 First Name
Tobacco Use:
MI
MI
Last Name
Gender
M
F
Never
Currently use tobacco products
Previously used tobacco products but stopped on (MM/YY): ________
11/1/14
Height
Weight
Date of Birth
Height
Height
Age
Weight
Social Security No.
-
Relationship to Applicant:
Age
-
Social Security No.
-
Relationship to Applicant:
-
Weight
Date of Birth
Height
Age
Weight
Date of Birth
-
Primary Care Physician:
Social Security No.
-
Relationship to Applicant:
Page 1 of 12
Primary Applicant First Name
MI
Last
Section 4 - Continued
Please answer the following questions if you are applying for any dependents other than your spouse:
Yes
No
1.
Yes
No
2. Are there documents establishing adoption, anticipation of adoption or guardianship for any children for whom you are applying?
If “Yes,” please submit a complete copy of the final documents including but not limited to the Final Order of Adoption, documentation
demonstrating the child has been placed with you in anticipation of adoption or a court order establishing guardianship.
Are all children for whom you are applying under the age of 26, and your (Please select all that apply):
Biological children
Adopted children
Step-children
Children placed with you in anticipation of adoption
Children for whom you are legal guardian?
If “No,” please explain _______________________________________________________________________________________
TRH reserves the right to request proof of continuing dependent eligibility at any time. In the event dependent eligibility cannot be determined based on the
answers submitted on the application, additional information may be requested.
Section 5
General Information
Please Read Carefully as this Contains Important Information
Quoted premiums are only an estimate. This application will be medically underwritten and TRH may need to adjust your premium based on the information
submitted on the application and any medical information submitted during the underwriting process. In addition to being medically underwritten, TRH
coverages are age-rated. Rate adjustments will occur as the oldest person on the contract ages. General rate adjustments may also be necessary. You will
be notified by letter thirty (30) days in advance of any rate adjustment.
Individual Coverage has no maternity benefits. Family coverage includes maternity benefits after a member’s coverage has been in effect for nine
consecutive months.
If you or anyone for whom you are applying is currently an expectant mother or father, completion of a Newborn Waiver is required before the application
can be processed. The Newborn Waiver establishes that the newborn child, upon delivery, will not have automatic coverage. A new application to add the
newborn child will be required and the child will be medically underwritten. After the application process is complete, the newborn child will be added to the
coverage on the next available effective date.
THE FOLLOWING PLANS CONTAIN AT LEAST A 12-MONTH PRE-EXISTING CONDITION WAITING PERIOD FOR ANY CONDITIONS THAT WERE IN
EXISTENCE PRIOR TO THE COVERAGE’S EFFECTIVE DATE FOR ANYONE ON THE CONTRACT AGE 19 AND ABOVE: COMPLETE CARE, MAJOR
MEDICAL, VALUE CARE, PREMIER AND HIGH DEDUCTIBLE (HSA-QUALIFIED).
CORE CHOICE CONTAINS AT LEAST A 6-MONTH PRE-EXISTING CONDITION WAITING PERIOD FOR ANY CONDITIONS THAT WERE IN
EXISTENCE PRIOR TO THE COVERAGE’S EFFECTIVE DATE FOR ANYONE ON THE CONTRACT AGE 19 AND ABOVE.
CORE CHOICE CHILD COVERAGE CONTAINS AT LEAST A 6-MONTH PRE-EXISTING CONDITION WAITING PERIOD FOR ANY CONDITIONS THAT
WERE IN EXISTENCE PRIOR TO THE COVERAGE’S EFFECTIVE DATE.
PREMIER CHILD COVERAGE CONTAINS AT LEAST A 12-MONTH PRE-EXISTING CONDITION WAITING PERIOD FOR ANY CONDITIONS THAT
WERE IN EXISTENCE PRIOR TO THE COVERAGE’S EFFECTIVE DATE.
A pre-existing condition is defined in the contract as: "An illness, injury, pregnancy or any other medical condition which existed at any time preceding the
effective date of coverage under this contract for which: medical advice or treatment was recommended by, or received from, a provider of health care
services; or symptoms existed which would cause an ordinarily prudent person to seek diagnosis, care or treatment." The pre-existing condition waiting
period applies regardless of any previous or current coverage (unless you are a dependent eligible to transfer from an existing TRH health plan). This is not
an application designed to accommodate the portability provisions of the Health Insurance Portability and Accountability Act (HIPAA); therefore,
portable/creditable coverage does not apply and no portion of your applicable pre-existing condition waiting period will be waived. Any and all claims that
are filed during this pre-existing condition waiting period will be reviewed by TRH to verify they are not related to a pre-existing condition.
Section 6
Health Questionnaire
Please Read Carefully as this Contains Important Instructions for Completing the Health Questionnaire
All health questions must be answered “Yes” or “No”. If any of the answers are “Yes”, please provide complete and accurate details in the space provided.
We are relying on the information you provide on this application to determine eligibility for coverage for you, your spouse and any children for whom you
are applying. Inaccurate or incomplete information provided on this application may constitute misrepresentation. Material misrepresentation could result in
amended coverage or termination of coverage. Your full signature is required next to any changes you make to your responses to these questions.
Additional medical information may be needed to complete underwriting. The applicant is responsible for requesting and obtaining medical information from
providers and ensuring the medical information is received by TRH. Any charges from providers associated with obtaining medical information must be paid
by the applicant.
The applicant is encouraged to keep a personal copy of all medical records submitted to TRH. Once medical records are submitted to TRH, the applicant
must contact the TRH Privacy Office to obtain a copy of medical records. The applicant will be a charged a fee for the return of medical records.
All persons age 40 and older and children age 25 months and under will automatically receive a request for medical information (details below). This
information may be submitted with the application to help expedite the application process.
The following medical records will be required for ages:
(a) 40 and older: COPY OF MEDICAL RECORDS WITH A CURRENT MEDICAL EXAM TO INCLUDE HEIGHT, WEIGHT AND BLOOD PRESSURE
READINGS (COMPLETED WITHIN THE LAST 6 MONTHS); A LIST OF CURRENT HEALTH CONDITIONS, CURRENT MEDICATIONS, AND
FASTING CHOLESTEROL (LIPID) PANEL TEST RESULTS AND FASTING GLUCOSE (SUGAR) TEST RESULTS (COMPLETED WITHIN THE LAST
12 MONTHS)
(b) 25 months and under: COPY OF MEDICAL RECORDS REGARDING ALL PEDIATRIC VISITS FROM BIRTH TO PRESENT TO INCLUDE THE
NEWBORN METABOLIC SCREENING RESULTS, IMMUNIZATION HISTORY OR STATEMENT OF INTENT TO IMMUNIZE
If medical information is not received by TRH within thirty (30) days from the date of the request, your application for coverage will expire. To reapply for
coverage, a new application and $6 application fee will be required.
When answering the questions in this application, consider the health of yourself, your spouse and all children for whom you are applying. Claims
experience from any previous TRH plan may be considered during the underwriting process.
Primary Applicant First Name
MI
Section 6 - A
Last
Heart / Circulatory
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Aneurysm
Yes
No
11.
Arrhythmia / Tachycardia / Heart Murmur / Palpitations
Yes
No
2.
Arteriosclerosis / Hardening of the arteries
Yes
No
12.
Heart Attack
Yes
No
3.
Blood Clot / Deep Vein Thrombosis (DVT)
Yes
No
13.
Heart Valve Disease / Replacement
Yes
No
4.
Varicose Veins, Chronic Venous Insufficiency
Yes
No
14.
Congenital Heart Defect
Yes
No
5.
Cardiomyopathy / Enlarged Heart
Yes
No
15.
High Blood Pressure / Hypertension
Yes
No
6.
Chest Pain / Angina
Yes
No
16.
Heart surgery of any type
Yes
No
7.
Congestive Heart Failure
Yes
No
17.
Shunt / Stent placement
Yes
No
8.
Kawasaki Disease
Yes
No
18.
Stroke / TIA
Yes
No
9.
Peripheral Vascular Disease
Yes
No
19.
High Cholesterol / Triglycerides / Lipids
Yes
No
Raynaud’s Disease
Yes
No
20.
Other Heart or Circulatory problems
Yes
No
10.
If you answered “Yes” to any of the above questions listed in Section 6-A, please explain below and provide full details.
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Section 6 - B
Hematology
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Anemia of any type
Yes
No
9.
Lymphadenitis / Lymph Node Enlargement
Yes
No
2.
Hemochromatosis
Yes
No
10.
High or Low Platelet Count
Yes
No
3.
Blood Transfusion
Yes
No
11.
High or Low White Blood Cell Count
Yes
No
4.
Hemophilia / other Bleeding Disorder
Yes
No
12.
Leukemia
Yes
No
5.
Blood Clotting Disorder
Yes
No
13.
High or Low Red Blood Cell Count
Yes
No
6.
Acquired Immunodeficiency Syndrome (AIDS)
Yes
No
14.
Enlarged Spleen
Yes
No
7.
Human Immunodeficiency Virus (HIV)
Yes
No
15.
Splenectomy / Surgical Removal of Spleen
Yes
No
8.
Mononucleosis / Epstein-Barr Virus
Yes
No
16.
Other Blood Disease or Disorder
Yes
No
If you answered “Yes” to any of the above questions listed in Section 6-B, please explain below and provide full details.
Question #
Applicant’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
Duration (MM/YY):
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Was Surgery Performed?
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
LG-FM13-216
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Page 3
Primary Applicant First Name
MI
Section 6 - C
Last
Endocrine / Metabolic
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Adrenal Gland Disorder
Yes
No
8.
Hyperglycemia / Hypoglycemia
Yes
No
2.
Addison’s Disease
Yes
3.
Cushing’s Syndrome
Yes
No
9.
Hyperthyroidism / Hypothyroidism
Yes
No
No
10.
Goiter / Thyroid Nodule / Thyroid Cyst
Yes
4.
Diabetes / Pre-Diabetes
No
Yes
No
11.
Grave’s Disease / Hashimoto’s Disease
Yes
5.
No
Gestational Diabetes
Yes
No
12.
Pituitary Gland Disorder
Yes
No
6.
Impaired Glucose Tolerance
Yes
No
13.
Metabolic Syndrome
Yes
No
7.
Insulin Resistance
Yes
No
14.
Other Endocrine / Metabolic Disorders
Yes
No
If you answered “Yes” to any of the above questions listed in Section 6-C, please explain below and provide full details.
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Section 6 - D
Digestive / Gastrointestinal
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Stomach or Gastric Ulcers
Yes
No
10.
Esophageal Reflux / Stricture / GERD
Yes
No
2.
Hiatal Hernia / Abdominal Hernia
Yes
No
11.
Gallbladder Disease / Cholecystitis
Yes
No
3.
Colon Polyps
Yes
No
12.
Pancreatitis
Yes
No
4.
Diverticulitis / Diverticulosis
Yes
No
13.
Hepatitis
Yes
No
5.
Crohn’s Disease
Yes
No
14.
Liver Cyst(s) or Abscess
Yes
No
6.
Irritable Bowel Syndrome / IBS
Yes
No
15.
Gastric Bypass / Lap Band / Weight Loss Surgery
Yes
No
7.
Ulcerative Colitis
Yes
No
16.
Enlarged Liver / Elevated Liver Enzymes (ALT/LFT)
Yes
No
8.
Hemorrhoids
Yes
No
17.
Cirrhosis of Liver
Yes
No
9.
Celiac Disease
Yes
No
18.
Other Conditions of the Digestive System.
Yes
No
If you answered “Yes” to any of the above questions listed in Section 6-D, please explain below and provide full details.
Question #
Applicant’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
Duration (MM/YY):
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
Duration (MM/YY):
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
LG-FM13-216
11/1/14
Page 4 of 12
Primary Applicant First Name
MI
Section 6 - E
Last
Kidney / Genitourinary
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Cystitis / Bladder Infections / UTI
Yes
No
10.
Birth Defects of Kidney / Ureter / Bladder
Yes
No
2.
Blood / Protein in Urine
Yes
No
11.
Kidney Transplant or Dialysis
Yes
No
3.
Interstitial Cystitis
Yes
No
12.
Chronic Kidney Disease
Yes
No
4.
Urinary / Stress Incontinence
Yes
No
13.
Nephrectomy / Surgical Removal of Kidney
Yes
No
5.
Urethral Stricture
Yes
No
14.
Renal Failure
Yes
No
6.
Kidney Stones
Yes
No
15.
Elevated Prostate-Specific Antigen (PSA)
Yes
No
7.
Kidney Reflux
Yes
No
16.
Enlarged Prostate / Benign Prostatic Hypertrophy (BPH)
Yes
No
8.
Kidney Infection
Yes
No
17.
Chronic or Recurring Prostatitis
Yes
No
9.
Polycystic Kidney
Yes
No
18.
Other Kidney / Genitourinary / Bladder Disorders
Yes
No
If you answered “Yes” to any of the above questions listed in Section 6-E, please explain below and provide full details.
Question #
Applicant’s Name:
Diagnosis, condition, or illness:
Is the Condition still present?
Doctor’s Name:
Duration (MM/YY):
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Diagnosis, condition, or illness:
Is the Condition still present?
Doctor’s Name:
Duration (MM/YY):
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Section 6 - F
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below? Please answer all questions regardless
of gender.
Yes
No
Yes
No
1. Irregular Menstrual Bleeding
9. Pregnancy Complications
2.
Abnormal PAP Smear
Yes
No
10.
Endometriosis / Fibroids (any type)
Yes
No
3.
Sexually Transmitted Disease (STD)
Yes
No
11.
Cystocele / Rectocele / Prolapse
Yes
No
4.
Herpes Simplex Virus (HSV)
Yes
No
12.
Polycystic Ovaries / Ovarian Cyst
Yes
No
5.
Human Papilloma Virus (HPV) / Genital Warts
Yes
No
13.
Hysterectomy:
Yes
No
6.
Abnormal Mammogram / Ultra Sound / Breast Exam
Yes
No
14.
Hormone Replacement Therapy
Yes
No
7.
Breast Biopsy
Yes
No
15.
Hydrocele / Varicocele / Spermatocele
Yes
No
8.
Breast Implants:
Yes
No
16.
Undescended Testicle
Yes
No
Silicone
Saline
Other
Partial
Complete
If you answered “Yes” to any of the above questions listed in Section 6-F, please explain below and provide full details.
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Was Surgery Performed?
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Was Surgery Performed?
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
LG-FM13-216
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Primary Applicant First Name
MI
Section 6 - G
Last
Musculoskeletal
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Osteoarthritis / Degenerative Joint Disease
Yes
No
13.
Carpal Tunnel Syndrome
Yes
No
2.
Rheumatoid Arthritis / JRA / Sjogren’s Syndrome
Yes
No
14.
Plantar Fasciitis
Yes
No
3.
Elevated or Positive Antinuclear Antibody (ANA)
Yes
No
15.
Osteoporosis / Osteopenia
Yes
No
4.
Gout, Gouty Arthritis
Yes
No
16.
Temporal Mandibular Joint Dysfunction (TMJ)
Yes
No
5.
Psoriatic Arthritis
Yes
No
17.
Joint Dislocation / Joint Replacement
Yes
No
6.
Reiter’s Syndrome
Yes
No
18.
Spina Bifida / Spina Bifida Occulta
Yes
No
7.
Bursitis / Tendinitis
Yes
No
19.
Back or Neck Injury / Pain
Yes
No
8.
Fibromyalgia
Yes
No
20.
Herniated / Ruptured / Bulging Disc
Yes
No
9.
Systemic Lupus Erythematous (SLE)
Yes
No
21.
Sciatica / Sacroiliitis / Radiculitis / Spinal Stenosis
Yes
No
10.
Connective Tissue Diseases of any type
Yes
No
22.
Scoliosis / Curvature of the Spine
Yes
No
11.
Bone Spurs
Yes
No
23.
Degenerative Disc Disease
Yes
No
12.
Bunion / Hammertoe
Yes
No
24.
Amputations / Birth Defects / Prosthesis
Yes
No
25.
Yes
No
26.
Any chiropractic treatment? If “Yes,” please specify:
For symptoms of pain or discomfort?
For wellness or maintenance only?
Hip pain, injury, or other conditions of the hip? If “Yes,” specify which:
Right
Left
Yes
No
27.
Knee pain, injury, or other conditions of the knee? If “Yes,” specify which:
Yes
No
28.
Ankle / Foot pain, injury or other conditions of the Ankle / Foot? If “Yes,” specify which:
Yes
No
29.
Shoulder pain, injury, or other conditions of the shoulder? If “Yes,” specify which:
Yes
No
30.
Elbow / Wrist pain, injury or other conditions of the Elbow / Wrist? If “Yes,” specify which:
Yes
No
31.
Internal / external fixations, screws, plates, or rods? If “Yes,” specify location and type in space provided below.
Yes
No
32.
Physical Therapy or Steroid Injections for any type of injury, inflammation or pain?
Yes
No
Right
Both
Left
Right
Both
Right
Left
Left
Right
Both
Both
Left
Both
If you answered “Yes” to any of the above questions listed in Section 6-G, please explain below providing details to include area of body, if
applicable.
Question #
Applicant’s Name:
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
Duration (MM/YY):
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
Duration (MM/YY):
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
Duration (MM/YY):
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
LG-FM13-216
11/1/14
Page 6 of 12
Primary Applicant First Name
MI
Section 6 – H
Last
Brain / Neurological / Behavioral
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Amnesia / Coma
Yes
No
15.
Tourette Syndrome / Tics / Tremor of any type
Yes
No
2.
Alzheimer’s / Dementia
Yes
No
16.
Restless Leg Syndrome
Yes
No
3.
Concussion / Head Injury
Yes
No
17.
Reflex Sympathetic Dystrophy (RSD)
Yes
No
4.
Abscess, Cyst, or Tumor of the Brain
Yes
No
18.
Insomnia / Problems with Sleep / Sleep Disorder
Yes
No
5.
Encephalitis / Hydrocephalus
Yes
No
19.
Narcolepsy / Cataplexy
Yes
No
6.
Meningitis
Yes
No
20.
Autism / Asperger’s Syndrome
Yes
No
7.
Headaches / Migraines
Yes
No
21.
Pervasive Development Disorder of any type
Yes
No
8.
Black-outs / Syncope / Fainting
Yes
No
22.
Anxiety / Depression / OCD / Panic Attacks
Yes
No
9.
Epilepsy / Seizure of any type / Convulsions
Yes
No
23.
Bi-Polar / Chemical Imbalance / Mood Disorder
Yes
No
10.
Multiple Sclerosis (MS) / Muscular Dystrophy
Yes
No
24.
ADD / ADHD / Adjustment Disorder of any type
Yes
No
11.
Paralysis / Partial Paralysis
Yes
No
25.
Anorexia / Bulimia / Eating Disorder of any type
Yes
No
12.
Neuralgia, Neuritis, or Neuropathy / Bell’s Palsy
Yes
No
26.
Self-Inflicted injury / Suicidal Thoughts / Suicide Attempt
Yes
No
13.
Cerebral Palsy / Down’s Syndrome
Yes
No
27.
Counseling / Therapy of any type
Yes
No
14.
Lou Gehrig’s / Parkinson’s Disease
Yes
No
28.
Other Brain / Neurological / Behavioral Disorders
Yes
No
If you answered “Yes” to any of the above questions listed in Section 6-H, please explain below and provide full details.
Applicant’s Name:
Question #
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
Is the Condition still present?
Was Surgery Performed?
What medications do you take for this condition or illness?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Applicant’s Name:
Question #
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Section 6 - I
Lung / Respiratory
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Allergies / Allergy Immunotherapy / Allergy Shots
Yes
No
9.
Tuberculosis
Yes
No
2.
Asthma / Reactive Airway Disease (RAD)
Yes
No
10.
Sarcoidosis / Granuloma of the Lung
Yes
No
3.
Abnormal Chest X-ray / MRI / CT of Lung
Yes
No
11.
Pleurisy / Pneumonia
Yes
No
4.
Abscess / Cyst / Lesion / Tumor of the Lung
Yes
No
12.
Respiratory Syncytial Virus (RSV) / Vaccinations for RSV
Yes
No
5.
Chronic Obstructive Pulmonary Disease (COPD)
Yes
No
13.
Chronic / Recurrent Tonsillitis / Enlarged Tonsils
Yes
No
6.
Emphysema
Yes
No
14.
Sleep Apnea
Yes
No
7.
Chronic coughing / Coughing up blood
Yes
No
15.
Been advised to have a sleep study?
Yes
No
8.
Cystic Fibrosis
Yes
No
16.
Do you currently use a C-PAP machine?
Yes
No
If you answered “Yes” to any of the above questions listed in Section 6-I, please explain below and provide full details.
Question #
Applicant’s Name:
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Is the Condition still present?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
Is the Condition still present?
Was Surgery Performed?
What medications do you take for this condition or illness?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
LG-FM13-216
11/1/14
Page 7 of 12
Primary Applicant First Name
MI
Section 6 - J
Last
Ear / Eye / Nose / Throat
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Cholesteatoma / Cyst of Ear
Yes
No
10.
Double Vision
Yes
No
2.
Deafness
Yes
No
11.
Ptosis / Drooping Eyelid
Yes
No
3.
Vertigo / Meniere’s Disease
Yes
No
12.
Glaucoma
Yes
No
4.
Chronic or Recurring Ear Infections
Yes
No
13.
Other Condition or Problem of the Ear(s) / Eye(s)
Yes
No
5.
Ear Tubes
Yes
No
14.
Chronis / Recurring Sinusitis
Yes
No
6.
Blindness / Partial Blindness
Yes
No
15.
Deviated Septum
Yes
No
7.
Cataracts
Yes
No
16.
Cleft Palate / Cleft Lip
Yes
No
8.
Corneal Implants / Ulcer
Yes
No
17.
Vocal Chord Polyps / Paralysis
Yes
No
9.
Retinal Detachment / Hemorrhage / Tear
Yes
No
18.
Other Condition or Problem of the Nose / Throat
Yes
No
Currently in Place
No Longer in Place
If you answered “Yes” to any of the above questions listed in Section 6-J, please explain below and provide full details.
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Section 6 - K
Skin
During the past ten (10) years, have you, your spouse or any children for whom you are applying, received medical advice or treatment; been
medically diagnosed with; or experienced symptoms for any of the conditions or diseases listed below?
1.
Eczema / Rosacea / Psoriasis
Yes
No
6.
Abnormal Moles / Abnormal Skin Lesions
Yes
No
2.
Seborrheic Dermatitis / Keratosis
Yes
No
7.
Cyst / Tumor of Skin
Yes
No
3.
Shingles / Herpes Zoster
Yes
No
8.
Skin Cancer
Yes
No
4.
Acne
Yes
No
9.
Biopsy of Skin / Biopsy of Skin Lesion
Yes
No
5.
Darier’s Disease
Yes
No
10.
Other Condition or Problem of the Skin
Yes
No
If you answered “Yes” to any of the above questions listed in Section 6-K, please explain below and provide full details.
Question #
Applicant’s Name:
Is the Condition still present?
Yes - Ongoing
No - Resolved
Diagnosis, condition, or illness:
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Was Surgery Performed?
Yes - (MM/YY) __________
Duration (MM/YY):
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
Question #
Applicant’s Name:
Is the Condition still present?
Diagnosis, condition, or illness:
Was Surgery Performed?
Duration (MM/YY):
Doctor’s Name:
From:
To:
What medications do you take for this condition or illness?
Yes - Ongoing
No - Resolved
Yes - (MM/YY) __________
No
Provide a detailed explanation regarding your treatment, any tests you were advised to have completed or tests actually completed and current
status:
LG-FM13-216
11/1/14
Page 8 of 12
Primary Applicant First Name
MI
Section 6 - L
Last
Miscellaneous Questions
When answering the following questions, consider the health of yourself, your spouse and all dependent children for whom you are applying:
1.
Has any applicant been rejected for coverage, issued a limited policy or issued a policy with increased premium for life, health, or
disability coverage? Applicant name(s): _________________ Reason: ____________________ Rejection Date: ___________
Yes
No
2.
Is any applicant currently on disability of any type?
Yes
No
Yes
No
Yes
No
Yes
No
Applicant name(s): ____________________
3.
Reason: ________________________________
Is any applicant currently covered under worker’s compensation? If “Yes,”
Applicant name(s): _______________________________
4.
5.
Type: __________________
Reason: _____________________________________________
Is any male applicant expecting a child with anyone, whether or not listed on this application? If “Yes,” the completion of a
Newborn Waiver is required.
Is any female applicant currently pregnant or has any female applicant tested positive using a home pregnancy test? If “Yes,” the
completion of a Newborn Waiver is required.
Applicant name(s): _______________ How many months pregnant? ______
What is the current pregnancy weight? _______
6.
Is every applicant up to date on recommended immunizations? If “No,” list Applicant name(s): ____________________________
Yes
No
7.
Is any child for whom you are applying under the age of 2 and born more than 2 months prematurely (32 weeks or less gestation)?
If “Yes,” Applicant name(s): ____________________________
Yes
No
8.
Have you or anyone for whom you are applying, experienced weight gain or loss of more than 20 pounds in the past 12 months?
If “Yes,” Applicant name(s): ________________________ Reason for weight gain or loss: ____________________________
Yes
No
9.
Within the past 10 years, has any applicant been treated, diagnosed with, or discussed with a physician the need to reduce
alcohol, chemical, prescription or substance use or abuse? If “Yes,” Applicant Name(s): ________________________________
Yes
No
10.
Within the past 10 years, has any applicant ever used illegal controlled drugs (prescription medications) or other substances such
as marijuana, cocaine, methamphetamine, or intravenous (IV) drugs? If “Yes,”
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Applicant name(s): ____________________ Type of drug/substance: ______________________ Date discontinued: _________
11.
12.
Has any applicant attended counseling, Alcoholics Anonymous (AA) or support groups for alcohol or drug use within the last 10
years?
Applicant name(s) ________________________________ Date started: __________________ Date ended: _______________
Within the past 10 years, has any applicant been treated for Chronic Pain with use of pain medications including but not limited to:
Oxycontin, Lortab, Morphine, or other pain medications? If “Yes,”
Applicant name(s): ________________________________ Name of Medication(s) : ___________________________________
13.
Is any applicant currently being treated or has any applicant been treated through a Pain Management Center? If “Yes,”
Applicant name(s) ________________________________ Date started: __________________ Date ended: _______________
14.
Has any applicant been advised to have surgery / biopsy that has not been completed? If “Yes,”
Applicant name(s): __________________________ Type of surgery / biopsy: __________________________
15.
Explain why the surgery / biopsy has not been completed: ________________________________________________________
Has any applicant been advised to have testing done that has not been completed? (i.e. blood work, x-ray, CT, MRI, Ultrasound,
etc.)
Applicant name(s): ___________________________________ Type of test(s): __________________________
Explain why the test has not been completed: ___________________________________________________________________
16.
In the last 3 years, has any applicant been referred to a medical specialist of any kind? (i.e. Cardiologist, Endocrinologist,
Oncologist, Neurologist, Pulmonologist, Urologist, etc.) If “Yes,”
Applicant name(s): __________________ Type of Specialist: ____________________ Final Diagnosis: __________________
Doctor’s Name: _____________________ Reason for referral: ___________________ Recovery Complete Date: ___________
17.
In the last 12 months, has any applicant been seen in the Emergency room? Applicant name(s): __________________________
Reason: __________________________ Final Diagnosis: __________________ Recovery Complete Date: ______________
List all medications that are currently being taken or that have been taken in the last three (3) years for you, your spouse, and any children for
whom you are applying. If necessary, please add a separate page with additional information.
What illness or condition is this
Is medication
Date
Applicant’s Name
Name of Medication(s)
Date Started
medication treating?
currently being taken?
Stopped
LG-FM13-216
11/1/14
Page 9 of 12
Primary Applicant First Name
Section 7
MI
Last
Acknowledgements and Agreements
Please Read Carefully and Initial Below
I understand and acknowledge:
 Any of the following coverages which may be issued will contain a pre-existing condition waiting period of at least 12
months for any person age 19 and above: Complete Care, Major Medical, Value Care, Premier and High Deductible
(HSA-Qualified) (Please initial here:________)
 Core Choice will contain a pre-existing condition waiting period of at least 6 months for any person age 19 and above.
(Please initial here:________)
 Core Choice Child Coverage will contain a pre-existing condition waiting period of at least 6 months:
(Please initial here:________)
 Premier Child Coverage will contain a pre-existing condition waiting period of at least 12 months:
(Please initial here:________)
 This is not an application designed to accommodate the portability provisions of the Health Insurance Portability and
Accountability Act (HIPAA); therefore, portable/creditable coverage does not apply and no portion of my applicable preexisting condition waiting period will be waived. In applying for this coverage, I understand and acknowledge that other
health insurance issuers make available to individuals other health coverage plans which do not require medical
underwriting and do not apply pre-existing condition limitations for individuals who have met certain prior creditable
coverage requirements. I hereby acknowledge that although such portable coverage may be available to me/us, based
on rates or other reasons, I have declined to apply for such coverage at this time. (Please initial here:________)
 I must immediately notify TRH when there is any change in the information submitted on this application concerning the
eligibility for coverage of any dependent, including my spouse. (Please initial here:________)
IMPORTANT: The approval of this application is subject to medical underwriting guidelines. If you have current coverage, do
not cancel your current coverage until you have been issued coverage by TRH and upon review, agree to accept the rate,
terms and conditions of the contract.
If approved for coverage, you will be mailed a billing statement for the initial amount due. This billed amount will need to be
paid by the due date. Once the billed amount has been paid, the automatic withdrawal from your bank account will begin on
or after the 1st of the following month.
Your TRH Plan ID card(s) and contract should arrive within a few days of the billing. Please review both the identification
card(s) and the contract carefully, as they contain important information. You will have 30 days from the date you receive
your contract to decide if you want to continue the coverage.
TRH is entitled to rely solely on the statements made on this application which are complete and correct.
I understand and acknowledge that any coverage which may be issued:
• Will be effective, subject to all the terms and conditions of the contract, on the date indicated with the issuance of the
identification card;
• Shall be binding only if each statement included on the application is complete and true; and
• May be transferable to another coverage classification within the TRH program.
LG-FM13-216
11/1/14
Page 10 of 12
Primary Applicant First Name
MI
Last
Please Read Carefully and Sign the Appropriate Box Below
I authorize any doctor, hospital, clinic, provider of health care, insurance or reinsurance company, or any other person or firm having any
information necessary to determine the eligibility of each person for whom application is made, to give to TRH or its affiliates, all such
information. I (or my personal representative) may request a copy of this authorization.
I understand the information in this application and any information obtained with this authorization will be used by TRH to determine
eligibility for coverage and that coverage and rates will be affected by this information. Rates resulting from an underwriting determination
more than 30 days in advance of the effective date could be subject to change.
If I am not already a member, I hereby make application for membership in the Tennessee Farm Bureau/TRH. I understand this
membership entitles me to apply for the services offered by TRH Health Plans and the Tennessee Farm Bureau.
I declare that the foregoing statements provided by me in this application in its entirety are true, correct and complete for myself, my
spouse and all children for whom I am applying.
I understand it is a crime to knowingly provide false, incomplete or misleading information to TRH for the purposes of defrauding the
company. Penalties include imprisonment, fines, and denial of coverage.
Acknowledgement for Individual Adult or Family Coverage
PLEASE COMPLETE THE FOLLOWING IF YOU ARE APPLYING FOR COMPLETE CARE, MAJOR MEDICAL, VALUE CARE,
PREMIER, HIGH DEDUCTIBLE (HSA-QUALIFIED) OR CORE CHOICE.
All individuals for whom application is made who are 18 years of age or older must sign and date the application, acknowledging
their understanding of and agreement to the conditions listed above.
__________________________
Applicant Signature
___________________
Today’s Date
__________________________
Spouse Signature
___________________
Today’s Date
__________________________
Dependent Signature
(age 18 and older)
___________________
Today’s Date
__________________________
Dependent Signature
(age 18 and older)
___________________
Today’s Date
__________________________
Dependent Signature
(age 18 and older)
___________________
Today’s Date
__________________________
___________________
Dependent Signature
Today’s Date
(age 18 and older)
Acknowledgement for Child Coverage (Age 19 and Under)
PLEASE COMPLETE THE FOLLOWING IF YOU ARE APPLYING FOR PREMIER CHILD COVERAGE OR CORE CHOICE CHILD
COVERAGE.
I declare that the foregoing statements provided by me in this application in its entirety are true, correct and complete for the child for
whom I am applying. I understand that if coverage is issued, I am the only person allowed to sign for changes to or cancellation of this
coverage.
____________________________________________________________
Signature of Subscriber Parent, Step-Parent or Legal Guardian
_________________________
Relationship
____________________________________________________________
Print Name of Subscriber Parent, Step-Parent or Legal Guardian
_________________________
Social Security Number
______________
Date
I declare that the foregoing statements provided by me in this application in its entirety are true, correct and complete for the child for
whom I am applying. I understand that if coverage is issued, I cannot sign for changes to or cancellation of this coverage. I understand as
parent or legal guardian of the child, I may, depending upon the age of the child, have the right to obtain information about this child’s
application and coverage if issued.
____________________________________________________________
Signature of Non-Subscriber Parent, Step-Parent or Legal Guardian
_________________________
Relationship
______________
Date
____________________________________________________________
Print Name of Non-Subscriber Parent, Step-Parent or Legal Guardian
A scanned, imaged or photocopied version of this completely executed form will have the same force and effect as the original document.
TRH Health Plans is a taxable, not-for-profit, membership organization which promotes health care for the rural people of Tennessee. Members can learn
more about the programs and services offered by TRH Health Plans through their local Tennessee Farm Bureau office.
$6 Application Fee (Non-Refundable)
LG-FM13-216
11/1/14
Page 11 of 12
Checklist for Completing
the TRH Application
Complete SECTION 1 with current information for you or the child for whom you are applying.
In SECTION 2, select the type of application.
In SECTION 3, choose one (1) plan and one (1) deductible (if applicable).
Complete SECTION 4 with current information and answer all questions regarding your spouse and all
dependent children for whom you are applying (if applicable).
Read SECTION 5 carefully as it contains important information.
In SECTION 6-A through SECTION 6-L, individually mark ALL QUESTIONS “YES” or “NO” for everyone
applying for coverage. List detailed information for every health question answered “YES.” Providing detail of
recovery, dates and doctors’ names may decrease the likelihood of more medical information being
requested. If necessary, please add a separate sheet with additional information.
In SECTION 6-L, list all medications for everyone applying, as requested. If necessary, please add a
separate sheet with additional information.
In SECTION 7 read and initial each area as requested to acknowledge your understanding. If applying for
individual adult coverage or family coverage, complete the Acknowledgement for Individual Adult or Family
Coverage box. If applying for individual child coverage, complete the Acknowledgement for Child Coverage
(Age 19 and Under) box.
Please thoroughly review and sign your FULL NAME beside any changes or mistakes made on the
application (even if white-out is used). Check the date that the application is signed. We cannot accept an
application more than 30 days old.
Complete the TRH Bank Draft Authorization (including payor information).
Complete the Patient Protection and Affordable Care Act (“PPACA”) Acknowledgment.
Complete the Farm Bureau Membership Application and Agreement form with EFT Agreement if you are not
currently a member, and submit a $25 check made out to Tennessee Farm Bureau for your annual Farm
Bureau membership dues.
Include a $6 application processing fee (per application submitted) made out to TRH Health Plans.
Return to TRH, P.O. Box 313, Columbia, TN 38402-0313, or deliver to your local Farm Bureau office. Go to
trh.com to locate an office near you.
◊ Completed TRH application
◊ Completed Bank Draft Authorization
◊ Completed PPACA Acknowledgement
◊ $6 application fee
◊ $25 membership fee and Farm Bureau Membership Application form with EFT Agreement (if applicable)
TRH's Toll-free number is 1-877-874-8323, 7:00 a.m. - 5:00 p.m., CST
Don't forget! Your Farm Bureau membership means you have access to an array of services -- including
automobile, homeowners and life insurance products, and discounts for security systems, cellular phone service
and hotels.
LG-FM13-216
11/1/14
Page 12 of 12
BL-FM07-005
INSTRUCTIONS FOR
BANK DRAFT AUTHORIZATION
The following must be completed to authorize your automatic bank draft after you pay the initial paper
invoice. If you are changing bank account information, this form must be received in our office ten (10)
days prior to the next scheduled draft date.
1. Signature of Applicant/Subscriber (Required) – Subscriber must sign and date that he/she
agrees to the terms and conditions as set forth in the Bank Draft Authorization. The Bank Draft
Authorization must be signed by parent or legal guardian if member is under age 19.
2. Signature of Payor (Required) and Print Payor Name (Required) – Payor (owner/signatory
of account) must sign and print name.
3. Applicant/Subscriber Name (Print) – Subscriber must print name.
4. Identification Number – Subscriber’s TRH identification number must be included.
5. Check “Health,” “Dental,” and/or “Prescription” box(es) that apply.
6. Check “Bank Change” box and write in effective date of change.
7. If personal account, check “Personal Account” box and check “Checking” or “Savings”
account. If business account, check “Business Account” box. Subscriber must be the
owner of the business or one (1) of two (2) employees. Please check appropriate box. If
Subscriber is not owner of business or an employee, a “Not An Employee” form must be
submitted.
8. Attach voided check to bottom of form if bank account is checking. Deposit slips will not be
accepted. If savings account, this form must be taken to your financial institution for
completion, including signature and telephone number of authorized representative.
9. Mail completed form to TRH Health Plans, P.O. Box 313, Columbia, TN 38402-0313, or you
may fax to (931) 560-4278, Attention: Billing Department.
10. Verify receipt of mailed or faxed form by calling (931) 388-7872 or toll free (877) 874-8323 and
request to speak to a Billing Department representative.
Please note: Federal law prohibits an employer from making payment for a Medicare
Supplement Plan for an active employee.
BL-FM07-005
BANK DRAFT AUTHORIZATION
 Health
 Dental
 Prescription (Check all that apply)
I hereby authorize TRH Health Plans (“TRH”) to initiate debit entries from the account indicated below
for the monthly payment of health, dental, or prescription coverage. The depository named below is
authorized to debit my account. I acknowledge I am authorized to sign this agreement on behalf of all
covered individuals and signatories to the account. I further understand I have the right to revoke this
authorization by notifying TRH in writing at least ten (10) days prior to the time payment is due. I
further agree that should a debit be dishonored, whether with or without cause and whether
intentionally or inadvertently, TRH shall have no liability whatsoever, even if such dishonor results in
forfeiture of coverage.
___________________________________________________
__________________________________________
Print Applicant/Subscriber Name (Required)
Print Payor Name (Required)
_______________________________________________
__________________________________________
Signature of Applicant/Subscriber (Required)
(Must be signed by parent, step-parent or legal
guardian of minor applicant)
Signature of Payor (Required)
________________________________
________________________________
________________________________
Date
County
Subgroup
________________________________
________________________________
________________________________
TRH ID Number-Health
TRH ID Number-Dental
TRH ID Number-Prescription
 Quarterly to Bank Draft ____________
 New Application
(effective date)
 Transfer
 Bank Change ____________
(effective date)
 ACCOUNT TYPE-  Checking  Savings
PLEASE READ CAREFULLY
For Checking Accounts: Attach voided check here (No Deposit Slips)
For Savings Accounts: Take form to Financial Institution for completion (No Deposit Slips)
________________________________________________________________________________
Name and Address of Financial Institution
_______________________________________
Routing Number
__________________________________
Account Number
___________________________________________________
Signature, Authorized Representative of Financial Institution
________________________
Telephone Number
Cancellation- The Subscriber may cancel this coverage for any reason by giving ten (10) days written
notice to TRH. Coverage will remain in effect until the paid-to date. Please see your contract for
specific information regarding cancellations and cancellations due to death of Subscriber.
LG-FM10-001
Patient Protection and Affordable Care Act
Acknowledgment
I hereby acknowledge my understanding of the following:
1. The health benefits coverage for which I am applying through TRH Health Plans is not
covered by the federal Patient Protection and Affordable Care Act ("PPACA") and does not
meet the current PPACA requirements for individual health insurance.
2. Under PPACA, individuals are required to purchase minimum essential coverage.
Since the TRH Health Plans coverage for which I am applying is not covered by PPACA,
and does not meet the PPACA requirements for individual health insurance, it is not
considered minimum essential coverage.
3. Because this TRH coverage is not considered minimum essential coverage, I will be
subject to a tax under the individual shared responsibility provision of PPACA.
______________________________________
Applicant Signature
_______________________
Date