Please read everything carefully and answer all questions honestly. This document becomes part of your health insurance contract.
Please complete all sections to the best of your ability. Please pay special
attention to the health history Section. By including the specific
details to questions you answered "yes" to - the processing of
your application will be expedited. Be sure to include:
The specific name and date of the diagnosis or condition and correct
The treatment(s) that were done, including the last time you visited
the doctor for this condition and medications that were prescribed and
medications that are currently being taken.
Final result refers to the status of the condition. If it has been
treated and your doctor has not requested any follow-ups, please state
so. If you are still seeing the doctor, please state so.
Complete name, address and phone number of the doctor.
Provide Certificate of Creditable Coverage (if available)
Please refer to Credit
for Prior Coverage Eligibility for more information. Please
note, if you do not have your Certificate of Creditable Coverage at the
time of application, please submit your application anyway. Credit for pre-existing
condition waiting periods will be credited upon receipt of your Certificate
of Creditable Coverage by ODS Health Plans of Oregon.
Children on the Application?
As of Sept. 23, 2010, federal health reform no longer allows insurance companies to deny coverage to children with pre-existing conditions. However, the law does allow insurers to limit enrollment to specific
times of year so that parents do not wait until a child becomes sick to buy coverage.
ODS will accept applications for enrollment of children with parent(s) throughout the year. Children may enroll in individual insurance throughout February and August of every year, starting with February
2011. Additional enrollment periods must be allowed in cases such as birth, adoption, or loss of coverage due to divorce or death of a parent. Under some circumstances, if a child’s coverage with
an insurance company ends, that company does not have to sell a new policy to the child for 12 months.
Monthly Bank Draft: Please complete Authorization
section carefully and attach a voided check. (deposit slip does not
Direct Bill: Simply check the Direct bill , and
you are done.
Final check list before mailing:
All sections completed?
Copy of Insurance Card or Certificate of Credible Coverage
Signed and Dated
Voided check if selecting the automated monthly withdrawal
Send all Enrollment Materials to:
CDA Insurance LLC
PO Box 26540
Eugene, OR 97402