By my signature below, I WISH TO ENROLL in my employer’s benefit plan. Furthermore, I 1) authorize my employer to deduct from my earnings my share of the payment for coverage, if applicable (or reduce my pay if my employer has a Section 125 Plan); 2) authorize any medical provider, lawyer, or any other person or entity to release, use and disclose any and all of my medical information to claim administrator, Entrust, Inc., for the adjudication, processing, and/or payment of any and all of my medical claims for benefits; 3) understand that this authorization will expire when my coverage under my employer’s benefit plan ends, which includes any coverage under COBRA; 4) affirm that I/we will abide by the provisions set forth in the SPD/Plan Document, which I authorize to be sent to me electronically, in addition to the Summary of Benefits & Coverage (provided to me on behalf of my applicable dependents unless a different address is specified for delivery), HIPAA Notice of Privacy Practices, and other important notices, such as Women’s Health & Cancer Rights Act, Medicare Part D, COBRA, CHIPRA, and Patient Protection & Affordable Care Act (PPACA) and if I/we request a paper copy, I/we may receive such without cost to me; 5) understand that consent to receive such documents electronically may be revoked at any time by contacting Entrust; 6) certify that the information provided pertaining to this enrollment is true; and 7) authorize the release of individually identifiable and/or otherwise protected health information to affiliated and non-affiliated third parties to the extent allowed under HIPAA; and 8) acknowledge this plan does not provide comprehensive major medical coverage; and 9) acknowledge that if I/we am qualified to receive a tax credit on the Health Insurance Exchange and enroll in the my employer’s benefit plan then I/we may be disqualified from receiving a tax credit or subsidy on a Health Insurance Exchange plan prior to the next open enrollment. I, on behalf of myself and my dependents,( if any), understand that our coverage may be reduced or terminated if we, individually or jointly, have made any false statements on enrollment, whether intentional or not, and further understand that by enrolling in my employer’s benefit plan, such enrollment does not represent a guarantee of benefit payments, and does not form or in any way alter any contract between myself and my employer. I further affirm that I have read and understood the above and if ANY of the above information changes, I will promptly notify my employer by completing an Enrollment Change Form.