Applicants
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Applicant name Application ID
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Attestation
I make the following statements separately for every applicant in this attestation:
The applicant, or the applicant’s authorized representative, completed the enrollment request by a method CMS allows, such as a signed paper enrollment application, or a recorded telephone enrollment using Elite Health Plan’s approved script in which they agreed to be recorded and stated their intent to enroll.
I have on file every enrollment document CMS requires for the applicant, which may differ from one applicant to another, such as the signed application or the complete call recording, the Scope of Appointment, and any other documentation the enrollment needed, for example Special Enrollment Period or authorized representative documentation. These documents are complete, accurate and compliant with CMS requirements.
For each personal marketing appointment with the applicant, I agreed on and documented the required Scope of Appointment before the appointment, in the format and within the timing rules that applied when it took place (42 CFR 422.2264(c)(3) and 422.2274(b)(3)).
When Elite Health Plan asks, I will send the signed originals, complete copies or complete recordings by the date in its request, including for an audit by Elite Health Plan or CMS.
I will keep these documents and recordings secure, protect the applicant’s information as HIPAA requires, and keep them for at least 10 years from the end of Elite Health Plan’s contract period with CMS or the completion of any audit, whichever is later, and longer while any legal hold applies (42 CFR 422.504(d), (e)(4) and (i)(2), and 422.2274(g)).
I am licensed and appointed to sell Elite Health Plan in California, and for the plan year of each application I completed the required training and passed the required testing (42 CFR 422.2274(b)).
Elite Health Plan relies on this attestation for these applications and its records of them. A false statement may lead to corrective action, including termination of my appointment, and Elite Health Plan will report to CMS and state authorities when required.
You changed your details or list after signing, so please confirm and sign again.
If any statement is not true for an applicant, for example if the signed application or the call recording no longer exists, do not sign. Remove that applicant, or contact Elite Health Plan .
I have read these statements. They are true for every applicant listed, and I agree to sign electronically. My electronic signature has the same legal effect as my handwritten signature.
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