I hereby apply for membership in National Workers Health Plan for myself and any eligible dependents and authorize my employer to make any deductions, as required as my contribution towards the premium. I hereby certify that the information furnished by me in this application is true and complete to the best of my knowledge and belief. I understand any material omission or misrepresentation may result in termination of enrollment and denial of insurance and will cooperate fully with NWHP to provide information necessary to coordinate benefits.
I authorize any physician, medical practitioner, hospital clinic, other medically-related facility, consumer reporting agency, insurance or reinsurance company or employer having certain information about my spouse, children, or by me to release NWHP or its legal representative, any and all such information. The nature of the information authorized to be disclosed includes information of physical conditions, health histories, avocations, ages, occupations, and personal characteristics. This authorization includes information about drugs, alcoholism, or mental illness. I authorize the compant to release any information obtained to reinsuring companies or other persons or organizations performing business or legal services in connection with my application, claim or as may be otherwise lawfully required or as i may further authorize. i agree that a photographic copy of this authorization shall be as valid as the origional.
Has anyone ever had, been medically advised they had been referred for counselling or treatment or been tested for the following:
Has anyone ever been medically advised they had, or been tested for:
