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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 11/1/14 2 of 12 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 11/1/14 Page 5 of 12 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