AgdaPkt 2005-06-27 - Laserfiche WebLink

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S. /(!- z.6 ' Please read thi~ Combined Evidence of Coverage & Disclosure Fonn ("Evidence of Coverage") completely and carefully to understand your Managed Health Network ("MHN') Employee Assistance Program ("EAP") benefits. This Evidence of Coverage discloses the terms and conditions of coverage and can help you understand your rights and responsibilities as an EAP member ("Member"). If you have behavioral healthcare needs, you should carefully read those sections that apply to you. Certain tenns are capitalized throughout this Evidence of Coverage - to help you understand these terms, the meaning and limitations of these terms are explained in the "Definitions" section of this booklet. This Combined Evidence of Coverage and Disclosure Form constitutes only_a summary of the health plan. The health plan contract (the "Agreement") between your employer ("Employer") and MHN must be consulted to determine the exact terms and conditions of coverage. You have the right to view the Evidence of Coverage prior to enrollment. Please review the Agreement to determine the governing contractual provisions. A copy of the Agreement will be furnished upon request. To receive a èopy of the Agreement or if you have questions or concerns after reading this Evidence of Coverage and need additional information about your EAP benefits (the "Plan"), please contact MHN at the number printed in this brochure. This Evidence of Coverage, the Agreement and benefits of this Plan are subject to change without your consent, according to the provisions of the Agreement. If this Evidence of Coverage has been issued to an existing MHN Group, it replaces the former Evidence of Coverage, effective upon the date in the Agreement. Please refer to the most recent Evidence of Coverage, as benefits may have changed from those-stated in the prior Evidence of Coverage. By enrolling in, or accepting services under, this Plan, Members agree to abide by all terms, conditions and provisions stated in the Agreement and this Evidence of Coverage. Members must notify MHN of any change in residence and any circumstances that may affect entitlement to coverage or eligibility under this Plan. Members cannot transfer the coverage and benefits of this Plan to another person without the prior written consent of MHN. Such a request may be denied for any reason, MHN reserves the right to make payment of benefits, at its sole discretion, directly to the Participating Practitioner. As a condition of enrollment and to receive benefits under this Plan - MHN, its agents, independent contractors and Participating Practitioners shall be entitled to release to, or obtain from, any person, organization or government agency, any information and records, including patient records of Members, which MHN requires or is obligated to provide pursuant to legal process, or federal, state or local law, Each Member expressly consents to, authorizes and directs Participating Practitioners, or others who are giving treatment or advice, to make available to MHN such medical and mental health reports. records and other information, or copies thereof, as MHN may request for the purposes of administering this Plan 3