Advantage Plus Enrollment Form
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1 Page 1 of 6 Advantage Plus Enrollment Form Colorado Region Thank you for your interest in our Advantage Plus plans. Combining the benefits of Advantage Plus with your Kaiser Permanente Senior Advantage (HMO) plan can enhance your health and well-being. Please read all pages of this enrollment form carefully before signing. Enrollment periods The Advantage Plus optional supplemental benefits package is only available to members who are enrolled in or have recently applied for a Kaiser Permanente Senior Advantage Individual Plan. New Senior Advantage member: If you are a new Senior Advantage member, you can add Advantage Plus within 30 days of your Senior Advantage effective date. Existing Senior Advantage member: If you already have Senior Advantage, you can sign up for Advantage Plus from October 15, 2018, until March 31, 2019 (your enrollment form must be received in our office by this date). How to enroll in Advantage Plus Online: You can complete the entire enrollment process online. Enrolling is fast and easy at kp.org/advantageplus. Mail: To enroll by mail, complete and mail pages 2 and 3 of this form. Please keep a copy of this form for your records. Do not send cash or check. You will be billed. If you have questions, please call us at (TTY 711), 7 days a week, 8 a.m. to 8 p.m. Return the signed form to: Kaiser Permanente Medicare Unit P.O. Box San Diego, CA Kaiser Permanente is an HMO plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal. Y0043_N _CO_FinalCO02_M _CO_FILL October
2 Colorado Advantage Plus Enrollment Form Page 2 of 6 Important information: Print in CAPITAL LETTERS and use blue or black ink only. Fill in check boxes with an X to mark your responses. A. Plan benefits Please choose an Advantage Plus plan option. (Not available under the Medicare Medicaid (HMO SNP) plan.) Advantage Plus Option 1: includes dental, hearing aids, and eyewear for $35 to be added to your Kaiser Permanente Senior Advantage monthly premium. Advantage Plus Option 2: includes acupuncture, hearing aids, and transportation for $14 to be added to your Kaiser Permanente Senior Advantage monthly premium. Advantage Plus Options 1 and 2: includes dental, hearing aids, eyewear, acupuncture, and transportation for $49 to be added to your Kaiser Permanente Senior Advantage monthly premium. B. Subscriber information Last name []]]]]]]]]]]]]]]]]]]]]]]]] Mr. Mrs. Ms. First name MI Gender Male Female []]]]]]]]]]]]]]]]]]]] [] Kaiser Permanente medical/health record # Medicare number (found on your Medicare card) []]-[]]]-[] []]]]]]]]]] Home phone number Alternate phone number Date of birth (mm/dd/yyyy) []]-[]]-[]]] []]-[]]-[]]] [] / [] / []]] Permanent residence street address (P.O. box is not allowed) City State ZIP code []]]]]]]]]]]]]]]]]]]]]]]] [] []]]] Mailing address, if different from permanent residence (P.O. box is OK) City State ZIP code []]]]]]]]]]]]]]]]]]]]]]]] [] []]]] address
3 Colorado Advantage Plus Enrollment Form Page 3 of 6 Subscriber name C. Conditions of enrollment By completing this application form: I agree to adding the Advantage Plus optional supplemental benefits package that gives me additional benefits for the option that I have selected for the additional premium, which is in addition to my Medicare and Kaiser Permanente Senior Advantage premiums. I understand that the Advantage Plus optional supplemental benefits package is only available to members enrolled in a Kaiser Permanente Senior Advantage Individual Plan. I understand that I must get covered care from network providers, except for emergency or urgently needed services. I understand that the optional supplemental benefits package that I have selected supplements my Senior Advantage coverage and is subject to the terms and conditions stated in the Kaiser Permanente Senior Advantage Evidence of Coverage. I understand that I can disenroll from Advantage Plus coverage at any time. If I disenroll, I will not be eligible to enroll until the next Advantage Plus annual election period for coverage effective January 1, I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application (including the Conditions of enrollment section above). If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment; and 2) documentation of this authority is available upon request by Kaiser Permanente or by Medicare. Signature Today s date (mm/dd/yyyy) [] / [] / []]] If you are the authorized representative, you must sign above and provide the following information: Name []]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]]] Address City State ZIP code []]]]]]]]]]]]]]]]]]]]]]]] [] []]]] Phone number Relationship to member []]-[]]-[]]] []]]]]]]]]]]]]]]]]]]]]]]
4 Page 4 of 6 Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats, such as large print, audio, and accessible electronic formats. Provide no cost language services to people whose primary language is not English, such as: Qualified interpreters. Information written in other languages. If you need these services, call Member Services at (TTY 711),8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to 2500 South Havana, Aurora, CO or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at _CO
5 Page 5 of 6 Multi-language Interpreter Services English ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Chinese 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711) Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください Amharic ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: 711). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711).
6 French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Page 6 of 6 Farsi توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی باشد. با (711 (TTY: تماس بگیرید. بصورت رایگان برای شما فراھم می Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: -117). Yoruba AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun yin o. E pe ero ibanisoro yi (TTY: 711). Cushite-Oromo XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Nepali ध य न दन ह स : तप इ ल न प ल ब ल न ह न छ भन तप इ क न म त भ ष सह यत स व ह न श ल क पम उपलब ध छ फ न गन र ह स ( ट टव इ: 711)
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