Police Health Plan Ltd is a member of Health Funds Association of New Zealand (HFANZ). On behalf of its members, HFANZ manages an Integrity Registry for the purposes of detecting and preventing fraud and other serious probity concerns. The Integrity Registry is operated by PricewaterhouseCoopers. Police Health Plan Ltd may collect, use and disclose personal and health information about you for the purposes of the Integrity Registry. You can access and correct information held on the Integrity Registry. Contact Police Health Plan Ltd or HFANZ Integrity Registry Privacy Officer, Health Funds Association of New Zealand, PO Box 25161, Wellington 6146.
- 1. I declare that:
- 1.1 All entries on this form are true and correct;
- 1.2 Any false answer may forfeit all right to any benefits from Police Health Plan Limited (Health Plan).
- 2. I agree:
- 2.1 to be bound by Health Plan Rules; and
- 2.2 that the information may be exchanged between Health Plan, NZ Police Association, Police Welfare Fund Limited and associated bodies (including Police Welfare Insurances Ltd, General Insurances Ltd and Police Welfare Fund Mortgages Ltd) for providing information on services and statistical, processing and underwriting purposes.
- 3. I understand that:
- 3.1 if I have agreed to take advantage of a discounted premium by selecting a voluntary excess, I agree to pay this excess amount towards any surgical procedures I may require.
- 3.2 if I select a voluntary excess and then choose to switch to a lower or no-excess option, a 90-day stand-down period will apply before the lower or no-excess option commences, and all conditions that were existing under the previous higher voluntary excess, will still incur that excess, regardless of when any procedure on this condition is carried out.
- 4. I authorise Health Plan to seek any further medical information as and when required.
- 5. I confirm I have read the Police Heath Plan Limited Rules (August 2017) and that I agree to be bound by the plan rules, terms and conditions.
- 6. I confirm that the Police Health Plan Limited, or any employee thereof, has not provided me with personalised financial advice other than general information about the Police Health Plan.