page 3 of 3 Disclosures and Signatures Please read the following carefully before signing. Delta Dental of California I understand that I am responsible for payment of the required premium and compliance with all of the provisions and conditions of the Disclosure Form/Contract. I hereby authorize my medical or dental care institution or professional to release to a representative of Delta Dental of California any personal, privileged or medical records information, including, but not limited to, my patient records, charts, X-rays, diagnosis histories, billing records, clinical abstracts or copies of consultations. The information authorized herein may be used for determination of benefits, quality assessment, utilization review, grievance resolution, or investigation or compliance with Delta Dental of California provider agreements or local, state or federal laws. The authorization is valid for the duration of the coverage. RIGHT OF REIMBURSEMENT: I, on my behalf of my dependent(s) listed on this Enrollment Application, hereby agree that in the event any dental services provided to me or my dependent(s) covered by Delta Dental of California are the primary financial responsibility of another party, because of other dental coverage, I will fully inform Delta Dental of California and will execute such assignments, liens or other documents that may be necessary to enable Delta Dental of California to recover the value of services and supplies provided. NOTICE: Any person who, with intent to defraud or knowing that he/she is facilitating fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud and may be subject to fines and confinement in prison. Sharp Health Plan ACKNOWLEDGEMENT: I authorize my employer to deduct from my earnings the contribution (if any) required to cover my share of the premium. I certify that I am working at the employer’s place of business in permanent employment. For enrollment in Sharp Health Plan, I understand that my dependents and I must live or work in the Plan’s service area. I understand that my employer’s application will determine coverage and that there is no coverage unless and until this application and an application made by my employer have been accepted and approved by Sharp Health Plan. I understand that California law prohibits an HIV test from being required or used by health care plans as a condition of obtaining coverage. AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL INFORMATION. PLEASE READ CAREFULLY BEFORE SIGNING BELOW. Sharp Health Plan is authorized to obtain and release medical information in compliance with the Confidentiality of Medical Information Act, Section 56 et seq. of the California Civil Code. I hereby authorize any physician, health care practitioner, hospital, clinic or other medical or medically related facility to furnish an agent, designee or representative of Sharp Health Plan any and all records pertaining to medical history, services rendered or treatment given to anyone enrolled hereunder or added hereafter for purpose of review, investigation or evaluation of any application or a claim. I authorize Sharp Health Plan or its agents, designees or representatives to disclose to a hospital, health care service plan or self-insurer any such medical information obtained if such disclosure is necessary to allow the processing of any claim. This authorization shall become effective immediately and shall remain in effect for 30 months to permit evaluation of this application, or for the term of coverage to allow the processing of claims. A photocopy of this authorization shall be as valid as the original. The Plan provides privacy protection that manages access to and use of race/ethnicity and language (REAL), sexual orientation and gender identity (SOGI) data. The Plan will utilize data to address disparities and focus quality improvement efforts toward providing appropriate services for REAL, SOGI and disability status services. Impermissible use of this data includes use of the data for underwriting and denial of coverage and benefits. MISREPRESENTATION: I have read and understood the provisions outlined within this form. All information I have provided on this form is true and correct. I understand that it is the basis on which coverage may be issued under the plan. Arbitration Agreement I represent that all the information supplied in this application is true and complete. I hereby agree to the conditions of enrollment of this application. I understand that any dispute or controversy that may arise regarding the performance, interpretation or breach of the agreement between myself (and/or any enrolled dependent) and Sharp Health Plan, whether arising in contract, tort or otherwise, must be submitted to arbitration in lieu of a jury or court trial if not satisfactorily resolved through Sharp Health Plan’s grievance process. Employee name (please print): Employee signature: X Date (MM/DD/YYYY): Declination of Coverage I have been notified that I and/or my eligible dependents are eligible for enrollment in my employer’s health benefits plan. By listing individuals for whom I am declining coverage and signing below, I voluntarily decline to enroll myself and/or those individuals and acknowledge that my decision to not elect coverage permits my employer’s health benefits plan to impose an exclusion from coverage until open enrollment, should I or these individuals later apply for coverage. ENTER 1 OR 2 BELOW: #1 - The individual declining coverage DOES have another employer health benefit plan, Medicare, Medi-Cal, military, or cross-border coverage. #2 - The individual declining coverage DOES NOT have one of the coverages listed in #1. # Name (last, first, M.I.): # Name (last, first, M.I.): # Name (last, first, M.I.): Employee signature: X Date (MM/DD/YYYY): 9/2023
