South West Surgical Associates 1 Member Contact Information2 Plan Options3 Dependents4 Payments Name* First Middle Initial Last Date of Birth* Gender* MaleFemaleTG FtoMTG MtoFSocial Security #*Email* Primary Phone*Other PhonePreferred Method of ContactPhoneEmailAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code If the employee does not want to participate in this Employer sponsored Employee Welfare Benefit Plan under the Employee Retirement Income Security Act of 1974, which plan complies with the Bronze level plan as minimum requirement under the Patient Affordable Care Act, then the employee agrees to waive their rights under this plan and to seek health insurance coverage individually and elsewhere and holds the Employer and the Employee Welfare Benefit Plan Trust harmless from any financial or physical consequences from the rejection of this coverage. The employee understands that if the coverage is rejected he or she will not be eligible for subsidies under the Patient Affordable Care Act. The decision to waive coverage has consequences for the employee. For example: Employees should be aware of the individual responsibility requirement taking effect in 2014 under the Affordable Care Act. An employee who refuses employer coverage and doesn’t obtain coverage on his or her own will be subject to a penalty. Unless the employee signs a waiver stating that they are covered under another plan, such as a spouse’s plan, Medicaid, or Medicare, the employee cannot enroll in your plan until the next open enrollment. However, if they are covered under another plan, but that coverage is lost, the employee can enroll in your plan immediately. There’s a time limit for enrolling after the other coverage is lost: the employee must request to enroll in your plan within 30 days of losing the other coverage. If the employee waives coverage without being covered under another plan, he or she (and the whole family) may be subject to a pre-existing condition limitation when he or she eventually enrolls in your plan. If the employee gains a new dependent through birth, adoption or marriage, he or she may enroll him/herself, the new dependent, and the entire family at that time, but the employee must do so within 30 days of gaining the new dependent. If the employee misses the 30-day enrollment deadline, he or she must wait until open enrollment. Check the box below ONLY if you REJECT this coverageTo continue the application for your Employee Welfare Benefit Plan, leave this box unchecked and click "Next". I HEREBY WAIVE THESE BENEFITS AVAILABLE UNDER THE EMPLOYEE WELFARE BENEFIT PLAN. ARE YOU SURE YOU WANT TO WAIVE COVERAGE?* YES Patient/Physician Health AgencyNo Deductable Community Health Co-op Program Plan Features Maximum Value Plan Minimum Essential Coverage Hospitalization Per Member $500 Daily Co-Pay Coinsurance None Calendar Limit of Hospital & Medical Per Person $6,350.00 Per Family $12,700.00 Lifetime Maximum Unlimited Physician Care Well Person Care: Annual Exams 100% covered Primary Care Physician Visits - ACO/PPC 100% covered Primary Care Physician Visits - ValuePoint $25 Copay $25 Copay Specialty Physician Visits $25 Copay Chiropractic $25 Copay Eastern Medicine/ Acupuncturist $25 Copay Naturopathic $25 Copay Diagnostic Imaging Selected Imaging Provider $0 Copay $0 Copay PHCS $250 Copay Laboratory Tests Selected Provider $0 Copay $0 Copay PHCS Limited Fee Schedule with $50 Copay Emergency and Urgent Medical Care Emergency Room $500 Copay Urgent Care Clinic - PHCS $75 Copay Ambulance for emergency care at hospital 100% covered Prescription Drugs $5 Generic and $50 Tier 2 Brand Name Dental, Vision, and Teledoc Included with Carrington Network Included with Carrington Network Plan type is an employer sponsored ERISA Trust using the services of Patient Physician Cooperatives.Plan Option*please select the plan option that is best for youMEC - Minimum Essential CoverageMVP - Maximum Value PlanProvider / Clinic NameVisit our Provider Directory to find a provider.Achi, Jyothi, MDAgu, Johnson, MDAjani, Dilawar, MDAjim, Alice, MDAlam, Anjum, MDAlhassan, Abdul-Aziz, MDAtaei, Homayoun, MDAvenue 360 Health & WellnessBallard, Kenneth, DOBellaire Doctors, MDBerry, Michelle, MDBlick, Mark, DOBlum, John, DOBolivar, Ricardo, MDBuxbaum, Michael, DOCasagrande, Michael, MDChia, Angela, MDChildrens Specialty Care Clinic, MDComplete Healthcare Services, P.A.Darveaux, Rene, MDDoctors Clinic HoustonDurand, Darnel, MDEzenwabachili, Obiajulu , MDFalcon, Arturo, MDFeng, Jessie, MDGreen, Demetris, MDGupta, Nandita, MDHameed, Mohammed, MDHaque, Mohammad, MDHasan, Shamsa, MDIbraheim, Nashaat, MDJanki, Patricia, MDJavaid, Muhammad, MDJeroudi, Mohamed, MDJohnson, Luckett, MDKaria, Ramesh, MDLatthe, Bharat, MDLe, Richard, MDMacDonald, Donald, MDManning, Everald, MDMao, Xun, MDMbogua, Caroline, MDMed-Cure Primary Care PhysiciansMi DoctorMireles, Jamir, MDMoonat, Suresh, MDMui, Bong, MDMurillo, George, MDMusa-Popeney, Faye, DONguyen, Hac, MDNguyen, Viet, MDNguyen, Nicole Nhan, MDNguyen, Phong, MDNguyen, William, MDNorth Cypress Family PracticeNorth Houston Family MedicineOkose, Peter, MDOsuji, Clara, MDPark, Joon, MDPatel, Nimesh, MDPatel, Dilipkumar, MDPatel, Vipul, MDPCP Associates Of Pasadena, P.APeganyee, Sukhdev, MDPham, Bao, MDPineda, Ramon, MDPremier Healthcare Group PLLCPucillo, Ronald, MDQadeer, Asaf, MDRana, Sanila, MDRizvi, Syed, MDSaleem, Agha, MDSamani, Kaveh, MDSarti , Fernando, MDSayeed, Fatima, MDShah, Parul, DOSim, Woon, MDSoleja, Nusrat, MDSpinks, David, DOStanley , Anne, MAOM, LAC, DIP OMStephen F. Austin Community Health CenterSyed, Tanveer, MDTahir, Saifuddin, MDThai, Ryan, MDThakkar, Heena, MDThakkar, Harish, MDTsao, Jerry, MDTse, Edward, MDVajpayee, Archna, MDWang, Jeff, DOWelcome Family Medicine, P.A.Willette, Roger, MDYrigoyen, Edmundo, MDZaw, Moe, MDLab Provider*Clinical Pathology LaboratoriesQuest DiagnosticsImaging Provider*Affordable MRIAngleton Open MRICentral Park ImagingExcel DiagnosticsHouston Medical ImagingSE Treatment CentersTexas MRI of LubbockOptional add-on services Stop Loss Coverage Pan Am Hospital Indemnity Coverage Add a spouse or dependent*YesNoFamily MembersPlease use the "plus" icon to the right of the table to add a dependent.First NameLast NameDate of Birth Gender MaleFemaleTG FtoMTG MtoFSocial Security #Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Relationship to PrimaryDependentSpouseOtherPlan Optionplease select the plan option that is best for youMEC - Minimum Essential CoverageMVP - Maximum Value PlanProvider / Clinic NameVisit our Provider Directory to find a provider.Avenue 360 Health & WellnessBlick, Mark, MDCheng, Danny, MDClinicas Mi DoctorDarveaux, Rene, MDDoctors Clinic HoustonFalcon, Arturo, NDGreen, Demetris, MDAtaei, Homayoun, MDLe, Richard, MDNorth Houston Family MedicineNwanna, E. Chinyere, FNP-CPara, Guillermo, MDPeganyee, Sukhdev, MDPham, Bao, MDPineda, Ramon, MDPucillo, Ronald, MDQadeer, Asaf, MDRana, Sanila, MDReddy, Malladi, MD, FACC, PASaleem, Agha, MDSarti, Fernando, MDSosa, Martha, PASpinks, David, DOStanley, Anne, MAOM, LAC, DIP OMStephen F AustinThai, Ryan, MDThakkar, Harish, MDTsao, Jerry, MDWillette, Roger, MDWilson, Inyang, PAYrigoyen, Edmundo, MDJohn, AbrahamThai, RyanAjim, AliceWali, GouherMbogua, CarolineLab ProviderClinical Pathology LaboratoriesQuest DiagnosticsImaging ProviderAffordable MRIAngleton Open MRICentral Park ImagingExcel DiagnosticsHouston Medical ImagingSE Treatment CentersTexas MRI of LubbockOptional add-on services Stop Loss Coverage Pan Am Hospital Indemnity Coverage Rep Name* First Last Method of Payment*Employer Paid Do you have any additional questions?MEMBERSHIP AGREEMENTS The health plan includes a prescription discount card, discounts on Dental, Vision, DME, Teladoc, Road Service Assistance, and Patient Advocacy through inclusion of your membership in the Patient/Physician Cooperative. I (we) agree to abide by the terms of the PPC membership as printed in the Membership Booklet. I (we) authorize the employer above to honor and pay these monthly charges. I (we) understand that in order to cancel these payments, I (we) must provide written notice to Patient/Physician Cooperatives and Group Employee Benefit Plan 30 days before the next scheduled payment. Until such notice is received, I (we) agree that you shall be fully protected in honoring any payroll deductions, bank charges or drafts. Primary Care Services Agreement I agree to a one year contract with my selected Provider for access to primary care services. I understand any request to change providers prior to the end of my 12 month contract must be submitted in writing to be reviewed & approved by Member Services. Imaging Services Agreement I agree to a one year contract with my selected Provider for access to Imaging Services. I understand any request to change providers prior to the end of my12 month contract must be submitted in writing to be reviewed & approved by Member Services. Lab Services Agreement I agree to a one year contract with my selected Provider for access to Lab Services. I understand any request to change providers prior to the end of my12 month contract must be submitted in writing to be reviewed & approved by Member Services. I understand that the health benefits under this Employee ERISA Trust Plan will become effective on the effective date shown in the Schedule of Benefits of the Certificate to be issued to me by the Trust. I declare that to the best of my knowledge and belief, all of the information contained in the enrollment form is true and correct and that no material information has been withheld or omitted. WARNING: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application/enrollment form containing any false, incomplete, or misleading information may be guilty of a crime and may be subject to fines and confinement in prison. Membership begins on the 1st of the month following enrollment. Payment Terms: Payroll Deduction, credit card, debit card, cash or check are accepted for the initial payment. Monthly fees must be paid by payroll deduction, credit card, debit card, or draft from checking or savings account. Payroll deductions are made at the time of the employer’s schedule payroll distributions. All drafts or credit / debit charges will be made on the 15th of the month prior to the month of service. Any payments or drafts that are refused by the bank or credit card will be considered delinquent. And any bank charges for an overdraft will be the responsibility of the member. All fees must be paid on the due date each month to remain current and an active member. When membership fees that are 30 days past due the benefits automatically terminate and will be reinstated only after the have been paid in full, past and current. Membership is for 12 month renewable terms. Members are responsible for fees for one full year at a time even though they may pay on a monthly basis. Member agrees to the above terms and conditions. I agree to the terms of the membership agreement Annual Membership Fees and Retainer Deposits Loan Pursuant to the Loan Agreement in the PPC Membership Directory of Benefits for value received, Borrower promises to pay Lender a total principal amount of $________________USD in return for receiving the following from Lender: cash for payment of the annual contract less the deposit made for Membership in Association and Retainer Funds for Medical Care Providers which loan amount will be repaid in monthly installments of $__________USD. HIPAA AUTHORIZATION STATEMENT OF INTENT It is my understanding that Congress passed a law entitled the Health Insurance Portability and Accountability Act (“HIPAA”) that limits disclosure of my protected medical information. This authorization is being signed because it is crucial that my medical providers readily give my protected medical information to the persons designated in this authorization in order to allow me the advantage of being able to discuss and obtain advice from my family and/or friends. Therefore, pursuant to 45 CFR 164.501(a)(1)(iv) a covered entity (being a health care provider as defined by HIPAA) is permitted to disclose protected health information pursuant to and in compliance with this valid authorization under 45 CFR Sec. 164.508. AUTHORIZATION I, {name}, an individual, hereby authorize all covered entities as defined in HIPAA, including but not limited to a doctor, (including but not limited to a physician, podiatrist, chiropractor, or osteopath,) psychiatrist, psychologist, dentist, therapist, nurse, hospitals, clinics, pharmacy, laboratory, ambulance service, assisted living facility, residential care facility, bed and board facility, nursing home, medical insurance company or any other health care provider or affiliate, to disclose the following information: All health care information, reports and/or records concerning my medical history, condition, diagnosis, testing, prognosis, treatment, billing information and identity of health care providers, whether past, present or future and any other information which is in any way related to my healthcare. Additionally, this disclosure shall include the ability to ask questions and discuss this protected medical information with the person or entity who has possession of the protected medical information even if I am fully competent to ask questions and discuss this matter at the time. It is my intention to give a full authorization to ANY protected medical information to the following authorized entity, its affiliates, employees and agents: Senior Patient Association 866-549-4199 dba Patient/Physician Cooperatives PO Box 1838Splendora, TX 77372 TERMINATION This authorization shall terminate on the first to occur of: (1) two years following my death or (2) upon my written revocation actually received by the covered entity. Proof of receipt of my written revocation may be by certified mail, registered mail, facsimile, or any other receipt evidencing actual receipt by the covered entity. This revocation shall be effective upon the actual receipt of the notice by the covered entity except to the extent that the covered entity has taken action in reliance on it. This authorization is not affected by my subsequent disability or incapacity. RE-DISCLOSURE By signing this Authorization, I acknowledge that the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the person or persons whose name(s) is/are written above, and the information once disclosed will no longer be protected by the rules created in HIPAA. No covered entity shall require my authorized persons to indemnify the covered entity or agree to perform any act in order for the covered entity to comply with this authorization. INSTRUCTIONS TO MY AUTHORIZED PERSONS My authorized persons shall have the right to bring a legal action in any applicable form against any covered entity that refuses to recognize and accept this authorization for the purposes I have expressed. Additionally, my authorized persons are authorized to sign any documents that the authorized persons deem appropriate to obtain the protected medical information. VALID DOCUMENT A copy or facsimile of this original authorization shall be accepted as though it were an original document. WAIVER AND RELEASE I hereby release any covered entity that acts in reliance on this authorization from any liability that may accrue from releasing my protected medical information and for any actions taken by my authorized persons. Member Agreement* Member agrees to the terms of service