2. Applying For Coverage:
3. Coordination of Benefits:
COMPLETE THIS SECTION IF YOU OR YOUR DEPENDENTS HAVE HEALTH AND/OR DENTAL COVERAGE UNDER ANY OTHER. BENEFITS WILL BE COORDINATED ACCORDING TO THE INDUSTRY STANDARDS.
4. Privacy Information:
AT MARITIME RESIDENT DOCTORS,WE RECOGNIZE AND RESPECT THE IMPORTANCE OF PRIVACY. WHEN YOU APPLY FOR COVERAGE, WE ESTABLISH A CONFIDENTIAL FILE THAT IS KEPT IN THE OFFICE OF MARITIME RESIDENT DOCTORS.WE LIMIT ACCESS TO PERSONAL INFORMATION IN YOUR FILE TO THE INSURERS/CLAIMS PAYERS OR PERSONS AUTHORIZED BY MARITIME RESIDENT DOCTORS WHO REQUIRE IT TO PERFORM THEIR DUTIES, TO PERSON TO WHOM YOU HAVE GRANTED ACCESS, AND TO PERSONS AUTHORIZED BY LAW. WE USE THE PERSONAL INFORMATION TO DETERMINE YOUR ELIGIBILITY FOR COVERAGE AND TOADMINISTER THE GROUP BENEFITS PLAN.
I HEREBY APPLY FOR COVERAGE UNDER THE GROUP BENEFITS PLAN ISSUED BY INSURERS/CLAIMS PAYERS. I AUTHORIZE THE INSURERS/CLAIMS PAYERS, ANY HEALTHCARE PROVIDER, MY PLAN ADMINISTRATOR, OTHER INSURANCE OR REINSURANCE COMPANIES ADMINISTRATORS OF GOVERNMENT BENEFITS OR OTHER BENEFITS PROGRAMS, OTHER ORGANIZATIONS, OR SERVICE PROVIDERS WORKING WITH MARITIME RESIDENT DOCTORS TO EXCHANGE PERSONAL INFORMATION, WHEN NECESSARY TO DETERMINE MY ELIGIBILITY FOR COVERAGE AND TO ADMINISTER THE PLAN. IF APPLYING FOR COVERAGE FOR MY PARTNER AND/OR DEPENDENTS, I CONFIRM THAT I AM AUTHORIZED TO ACT ON THEIR BEHALF. I AGREE THAT A PHOTOCOPY OR ELECTRONIC COPY OF THIS AUTHORIZATIONS AND DECLARATIONS SECTION IS AS VALID AS THE ORIGINAL. I CERTIFY THAT THE INFORMATION GIVEN IS TRUE, CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Member Name
Date Signed
I verify that all of the information is accurate and that I am the person named above.