Individual & Family Plan Off Exchange - Applications

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Let's Get Started on your Individual and/or Family Plan Application

Name of Applicant*

Prefix First Middle Last Suffix

Applicant Email*

Applicant Phone*

Reason for Application*

Proposed Effective Date*

The proposed effective date must be within 60 days of filling out and submitting this form. In addition, coverage only starts on the 1st of the month. That's why you only have 2 options to chose from for your proposed effective date.

Current Member ID*

Current Plan*

Select a Plan

Optional Riders:

Balance offers Optional Supplemental Dental and Vision options to meet your benefit and financial needs. * Note that these benefits apply to in-network dental and vision providers only.

Adult Vision - $3.92 per Member per month (VSP)

Adult Dental - $18.05 per Member per month (Delta Dental)

One Medical

YES, I want to join One Medical

Add the People You Want to Cover in Your Health Plan

Applicant Information

Name	Date of Birth	Actions

There are no Entries.

Insurance Agent or Broker Information

Are you using an Insurance Agent or Broker?*

Yes

No

Broker Name*

Prefix First Middle Last Suffix

Broker's Email*

Broker's Phone*

Broker's Fax

Broker's Company Name*

Broker's Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Condition of Application

General Conditions
Balance by CCHP reserves the right to reject any application for enrollment.
1. I understand that I have no coverage under this application until notified by Balance that I am accepted.
2. If I am accepted,this application will become part of the agreement between Balance and myself. Enrolled family members and I agree to be bound by the arbitration clause in the Balance contract instead of trial by a court or jury.
3. I understand that willful misrepresentation can result in rescission of my coverage. Balance can only rescind for a material misrepresentation or omission if them is representation or omission is willful.
Acknowledgment and Agreement
I hereby subscribe for myself and any enrolled dependents to the health plan designated here and agree to abide by all terms, conditions and provision of this Individual Membership Contract. I have read and understand the terms on this application and my signature below indicates my acceptance of these terms and that the information entered in this Application is complete, true and correct. I agree to notify Balance promptly of any facts or circumstances which arise before the effective date of coverage under Balance which make any of the statements supplied herein incorrect. I understand that coverage may be cancelled if Balance demonstrates I have been fraudulent orintentionally misrepresented material fact in my application.
Disclosure of Personal and Health Information
Balance understand the importance of keeping your and your dependents’ personal and health information private. Balance protects this information in electronic, written, and oral forms when used throughout our company. Balance will not disclose this information without your authorization except as permitted by law. For the purpose of administering your Balance coverage, Balance is permitted by state and federal law to obtain your and your dependents’ health information from a health care provider, insurer, insurance support organization, health plan, or your insurance agent. Also, by state and federal law, Balance is permitted to disclose your and your dependents’ health information to a health care provider, insurer, insurance support organization, health plan, or your insurance agent. A complete explanation of Balance policies and procedures (“Notice of Confidentiality and Privacy Practices”)for preserving the confidentiality of your personal and health information is available and will be furnished to you upon request by calling the Customer Service Department or by accessing Balance’s website.
Arbitration Agreement
I understand that (except for Small Claims cases) any and all disputes, including claims of medical malpractice (that is as to whether any medical services rendered under the health plan were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), which may arise under the agreement between me and my dependents enrolled in the plan and Balance and any of its affiliates shall be determined by submission to binding arbitration as provided by California law. Any such dispute will not be resolved by a lawsuit or resort to court process except as applicable law provides for judicial review of arbitration proceedings. ALL PARTIES TO THIS CONTRACT, BY ENTERING INTO IT, ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAWBEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF BINDING ARBITRATION. For more information regarding binding arbitration, please refer to your Evidence of Coverage.

Applicant Signature*

Applicant Name*

Only One More Thing

How did you hear about us?

Referrals

Newspaper

TV

Radio

Street Fair/Event

Email Ad

Mobile Ad

DM

Other

Where else did you hear about us?*

Confirm Your Information

If there are any issues with the information below, please hit the back button at the bottom of the form and edit your submission.

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Individual & Family Enrollment Application (Off Exchange)