*CommunityCare I.D. Number

*Employer Name

*Group Number

Employee Name

*Last

*First

Middle Initial

*Street Address

*City

*State

*Zip Code

*Home Telephone

*Work Telephone

Extension

By signing/submitting this form, you represent to CommunityCare that you have the ability to access information and consent to access documents and materials related to your CommunityCare benefits electronically, via the Internet. This consent applies to the following types of documents: Summary of Benefits (Member Handbook), provider directories, benefit grids, coordination of benefits (COB) forms, mail order prescription drug applications, 24-hour nurse line information and general HMO resource materials.

You may withdraw this consent annually without charge by calling our Member Services department or sending a letter to the following address: P.O. Box 3249, Tulsa, OK 74101-9953. You have the right to request and obtain a paper version of an electronic document free of charge.

To access electronic documents, you will need access to the Internet and Adobe Acrobat Reader. To retain electronic documents, you may print hard copies or retain them electronically on an electronic storage device (e.g., computer hard drive, CD, DVD, etc.). Access CommunityCare’s Web site at www.ccok.com.

*Employee Signature

*Date