HealthChoice Enrollment Agreement

Statement of Understanding

I understand that I may call my personal doctor at any time for medical advice, care or a referral if myself or anyone in my family covered by HealthChoice is sick or injured.

I understand that unless I have a medical emergency, I must contact my personal doctor for medical care. I understand that in an emergency, I must contact my personal doctor or the Managed Care Organization (MCO) as soon as possible, after I have received emergency care.

I understand that I am choosing to enroll in the MCO indicated and selecting a primary care doctor for myself and for each family member on this form.

I understand that receiving health care services without my personal doctor or MCO approval may result in a denial of payment by the MCO and may result in my being billed for the service. HealthChoice is not responsible for the bill and will not pay for the services if I do not follow the required directions of the MCO.

I understand that, after twelve months, I may change MCO once a year without giving a reason and that I may change MCOs at any time with an approved reason and that I can call the HealthChoice Enrollment line for help.

I understand that it is my responsibility to notify the MCO and my caseworker of any change in the number of my family members.

I understand that I must follow Medical Care Program regulations to stay eligible for HealthChoice.

I understand that all information is confidential.