ACKNOWLEDGMENTS
BY COMPLETING AND SIGNING THIS FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:

• This Application is not coverage. Coverage will not begin until (1) the effective date of the policy and (2) the first month's payment is made.
• If I use an agent or broker, they cannot accept risks or change BCBSTX policies or rules.
• If an agent, producer or broker was helping me to purchase an individual or family health or dental plan, BCBSTX may pay the broker a commission and/or other payment. If I want more detail about any payment to the agent or broker, I should ask the agent or broker.
• If any person knowingly submits a false claim for payment of a loss or benefit or falsely misstates an important fact on this Application, coverage may be rescinded. This includes false claims or facts about me or any of my dependents. Rescission cancels the coverage back to the first day it became effective. I will be given at least 30 days´ written notice before my coverage or that of my dependents is rescinded.
• My monthly premium will be calculated using factors approved by the State's Department of Insurance and other applicable State and Federal laws and regulations. Rates are calculated based on age, tobacco use and geographic rating factors. These factors are also used to calculate premiums for any dependents covered on my policy.
• Coverage will start on the plan effective date only if the first monthly payment is received in full before that date.
• I allow any of the following people or organizations to share my health information with BCBSTX or their authorized representative:
• Health professionals, hospitals, or clinics
• Other health or health‐related facilities
• Government agencies
• Pharmacy benefit managers, clearinghouses, or retail stores
• Any other persons or firms required by law
–  This information may include:
• Copies of records about advice, care or treatment that were given to me and/or my dependents
• Information about the prescription and use of drugs or alcohol (without limitation)
• Information about mental illness
• BCBSTX may review and research its own records for information.
• BCBSTX will share collected information only as needed with medical entities to help manage my care.
• Information shared with my authorization may be re-shared by BCBSTX as allowed or required by law. If such sharing is required, the person or agency getting the information will be responsible for protecting it.
• This authorization is valid for two years from today, or until I cancel coverage.
  –  I have the right to cancel the authorization at any time, in writing, by contacting BCBSTX.
  –  I or anyone I authorize to represent me will receive a copy of this authorization upon request.
  –  Any cancellation will not affect the activities of BCBSTX before the date such cancellation is received by BCBSTX.
• I present any statements and answers on this Application as FACTS. To the best of my knowledge and belief, they are true and complete. These facts are the basis of my Application.
• The Application will become a part of the contract between BCBSTX and me.
• My agent (if I have one) and I confirm that I have read and understood the Application.
• I have reviewed the details of the plan I chose.
• This individual or family plan is meant to be paid as my personal expense.
• Only I or a family member, or an allowed third party as outlined in the Application will pay BCBSTX directly.
• BCBSTX does not accept payments directly from third parties except from those listed on page 8 (family members, Required Entities, certain private nonprofit foundations).
• If these rules are broken, any payments made by a third party will not be credited to my account or coverage. These payments may not be refunded to me. This may result in the cancellation of my coverage for nonpayment.

WARNING: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR THE PAYMENT OF A LOSS IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES AND CONFINEMENT IN STATE PRISON.

HMO Disclosure BY COMPLETING AND SIGNING THIS FORM, I UNDERSTAND AND AGREE TO THE FOLLOWING:

TEXAS DEPARTMENT OF INSURANCE REQUIRED DISCLOSURE NOTICE FOR ALL CONSUMER CHOICE HEALTH BENEFIT PLANS ISSUED IN TEXAS

Under Texas law, HMOs are permitted to market "Consumer Choice" plans, which do not have to comply with one or more state coverage requirements. They must also offer a plan that does comply with all state requirements. HMOs are required by law to obtain signatures of consumers showing they have been given this notice.

I have been informed that the consumer choice plan I am being offered does not include all of the health benefits usually required by Texas law. I understand that the following benefits are either excluded from the plan or provided at a reduced level:

I understand that if I buy a consumer choice plan, the HMO may deny or limit coverage for these services for me and anyone else covered by my health plan when the health needs of anyone covered under my plan changes. I understand that I can get more information about consumer choice plans from the Texas Department of Insurance (TDI) by visiting the TDI website at http://tdi.texas.gov/consumer/consumerchoice.html or by calling the TDI Consumer Help Line at 1-800-252-3439.

NOTE : The HMO issuing the policy must keep this disclosure statement and provide it to the commissioner of insurance on request. You have the right to a copy of this written disclosure statement free of charge. You must sign a new disclosure statement when you buy a consumer choice plan and each time your policy renews.