APPLICATION TERMS AND CONDITIONS AGREEMENT
I hereby acknowledge and agree that all of the information I have provided to the Wichita Cancer Foundation (“WCF”) on this application (this “Application”) for insurance premium financial assistance (the “Assistance”) is true and accurate in all respects. I understand that at any time after submitting this Application that I may be contacted to provide documentation evidencing any of the eligibility requirements, including, without limitation, insurance and financial information. I agree to respond to any request from WCF regarding such documentation within the time period requested and failure to timely respond will make me ineligible to receive the Assistance. I acknowledge and understand that I have the right at all times to choose my healthcare providers, practitioners, pharmacies, insurers or other health care suppliers without affecting my eligibility for the Assistance. I understand this Application does not guarantee the Assistance will be provided. I understand that if I am selected to receive the Assistance, my insurance premiums will be paid directly to my insurance carrier for the number of months determined at the sole discretion of WCF not to exceed six (6) months. Thereafter I must reapply for the Assistance. Assistance at any time is always subject to the availability of funds and there is no guarantee such funds will be available. I agree that WCF may change or cancel the premium financial assistance program at any time.
I understand that although the Assistance will be paid on my behalf directly to my insurance carrier, it is still my responsibility to verify the payment was received and processed successfully every month prior to the expiration of any grace period. I acknowledge and agree that all invoices, notices and general correspondence from my insurance carrier will continue to come to me at my contact information. Therefore, I am also responsible for forwarding all correspondence and notices related to the payment of my premiums immediately upon receipt to WCF.
I agree that, (a) if at any time during the period in which I’m receiving the Assistance from WCF my insurance benefits change, (b) I am no longer in need of assistance, (c) in need of less assistance, (d) or my circumstances affecting my annual household income calculation change, including household size or income, I will immediately notify WCF with such change. I acknowledge and agree that such changes may impact my ability to continue to receive the Assistance, including a reduction in the amount of the Assistance or a termination of the Assistance entirely. All assistance granted is based upon the eligibility requirements and program rules established by WCF, as updated from time-to-time in WCF’s sole discretion. I understand that not all applicants are eligible for participation.
I understand that the amount of the Assistance that I receive may only cover my insurance premiums in part. If the Assistance does not cover my monthly insurance premium in full, I understand that I must pay the balance of such premiums. I understand that a policy of health care insurance that is underwritten to cover me is my responsibility and I must ensure that the related insurance premiums are paid in accordance with the insurance contract terms and conditions. I agree to contact WCF if I receive a notice of cancellation, non-renewal, or denial of insurance as such information may impact my ability to receive the Assistance from WCF.
AS A CONDITION TO MY APPLICATION FOR BENEFITS AND, IF ACCEPTED, MY RECEIPT OF ANY BENEFITS PROVIDED BY WCF, I HEREBY UNDERSTAND AND AGREE THAT IN NO EVENT SHALL WCF, OR WCF’S BOARD OF DIRECTORS, EMPLOYEES, AGENTS, CONTRACTORS OR VOLUNTEERS (THE “WCF PARTIES”) BE LIABLE FOR ANY DAMAGES, WHETHER ACTUAL, CONSEQUENTIAL, SPECIAL, PUNITIVE OR OTHERWISE, IN THE EVENT ANY PAYMENT MADE OR ATTEMPTED TO BE MADE BY WCF ON MY BEHALF IS DENIED OR OTHERWISE NOT ACCEPTED, OR FAILS TO BE RECEIVED, BY ANY INSURANCE CARRIER, FOR ANY REASON WHATSOEVER, INCLUDING, WITHOUT LIMITATION, DUE TO ANY NEGLIGENCE OR OVERSIGHT BY THE WCF PARTIES. TO THE MAXIMUM EXTENT ALLOWED BY LAW, I HEREBY FOREVER WAIVE, RELEASE AND DISCHARGE THE WCF PARTIES FROM ANY AND ALL CLAIMS, LIABILITY, ACTIONS, SUITS, DEMANDS, COSTS, EXPENSES OR INDEBTEDNESS THAT I MAY HAVE IN THE FUTURE AGAINST THE WCF PARTIES IN ANY WAY RELATED TO THE CANCELLATION OF, NON-RENEWAL OF, OR DENIAL OF INSURANCE (OR ANY SUCH APPLICATION OF INSURANCE), OR OTHERWISE RELATED TO ANY BENEFITS RECEIVED OR TO BE RECEIVED BY ME FROM WCF.
I authorize the use and disclosure of my personal information by WCF, to process this Application, to verify my eligibility and to do whatever is necessary to provide the Assistance to me if my Application is approved. I authorize my health care provider and insurance benefit provider (including my insurance benefit providers’ administrator, if applicable) to disclose to WCF my personal information they may have for the purposes set forth herein. I also authorize WCF to use my personal information for the purpose of analyzing, evaluating and improving the WCF insurance premium assistance program. I understand that once my personal information is released pursuant to this authorization that it may be subject to re-disclosure. This authorization is voluntary and may be revoked at any time; provided, however, that such revocation shall be limited to the extent that action has been taken in reliance on the authorization prior to revocation. If I revoke this authorization, I will no longer be eligible to receive the Assistance. All requests to revoke authorization shall be given to WCF in writing at: Wichita Cancer Foundation, Attn: President P.O. Box 49020 Wichita, Kansas 67201-9020.