Send all required documents (including this checklist) to:
|
|
- Rudolph Kelly Todd
- 5 years ago
- Views:
Transcription
1 hsainsurance.com Fallon Community Health Plan Fallon Senior Plan Companion Care To ensure that your applications are processed as quickly as possible, just follow this checklist 1 Employer completes and signs the Master Application. 2 Employer provides copy of most recent Schedule C or WR-1. Check if Complete 3 Pay your first premium: Pay over the phone: (781) Payment Confirmation #: -or- Complete Electronic Payment Request Form -or- Enclose check payable to Health Services Administrators (HSA) (Receipt of payment does not guarantee coverage. HSA must receive completed enrollment materials by the carrier deadline) 4 Enclose Annual Membership Fee of $125 (Payable to HSA) -or- If enrolling through an Association or Chamber of Commerce, please indicate name of Association or Chamber * If not already a member of a participating Association or Chamber of Commerce, additional requirements may apply such as completing a membership application and paying dues. 5 Eligible enrollee completes and signs a Fallon Senior Plan Companion Plan Enrollment Form. 6 Eligible enrollee writes in their Medicare number and effective dates of Part A and B on Enrollment Form and includes a copy of their Medicare card or letter from the Social Security Administration. HSA Main Office 135 Wood Road Braintree, MA HSA Regional Office 574 Boston Road Billerica, MA Send all required documents (including this checklist) to: Sales Rep: Contact Info: All coverage will be effective on the 1 st day of the month. Enrollment materials should be received by the 25 th of the preceding month. Keep a copy of your application as your temporary ID. Once your enrollment have been approved and processed, you will receive a member confirmation by mail with your group number. Your permanent ID cards will be issued to you directly from the carrier. Permanent ID cards generally take 7-10 business days from date your enrollment was approved and processed. Corporate Office: 135 Wood Rd, Braintree, MA (781) (877) (781) fax Regional Office: 574 Boston Road, Billerica, MA Rhode Island Office: 2220 Plainfield Pike, Cranston RI (401) (401) fax
2 hsainsurance.com Fallon Health Companion Care The Companion Care Plan from Fallon Health offers more benefits at lower cost than most other options available to Medicare eligible recipients in Massachusetts. Members may go to any Medicare approved physician or hospital anywhere in the USA that accepts Medicare. Among the added benefits is unlimited prescription drug coverage. The monthly premium for this Medicare plan is $559 and is guaranteed through December 31, Eligibility Guidelines Eligible Companies An Eligible company is one that: Employs less than 20 total employees (includes full and part time) Is actively in business Is located in the Fallon Senior Plan service area Is a member in good standing of HSA Eligible Enrollee An eligible enrollee is one that: Is enrolled in Medicare Part A and Part B Lives in the United States Effective Dates All coverage will be effective on the 1 st day of the month Applications must be received by HSA by the 25 th of the month.
3 hsainsurance.com Fallon Health Senior Plan Member Application 2015 V1 Company Name Desired Effective Date Business Address (street, city, state, zip) Billing Address (if different) Principal Contact Telephone Fax Type of Business Corporation Proprietorship Partnership Other Nature of Business SIC code Date Established Tax ID Number Number of Full Time Employees Number of Seasonal Employees Number of Part Time Employees How many were employed 12 months ago? Information Related to Medicare Secondary Payer (MSP) Group attests that group has fewer than 20 employees as defined in the Medicare Secondary Payer regulations at 42 CFR : An employer is considered to employ 20 or more employees if the employer has 20 or more employees for each working day in each of 20 or more calendar weeks in the current calendar year or the preceding calendar year. The total number of current employees who receive wages, tips or other compensation (refer to line 1 of your most recent federal tax return form 941 or 944): Previous Year Q1 Q2 Q3 Q4 Current Year Q1 Q2 Q3 Q4 (includes FT, PT, seasonal, new hire) as of this date (mm/dd/yyyy). Are you offering this Medicare plan for retirees, active employees aged 65 or older or both? Do you offer group Commercial insurance for your under age 65 employees? If yes, current carrier(s)
4 Plan Selection Fallon Health Choose plan: SENIOR PLAN HMO SENIOR PLAN Companion Care Office co-pay In-network: $15 PCP $25 Specialist $0 Any doctor who accepts Medicare patients Rx Y Y Certification 1. I understand that all premiums for health/dental insurance are due on or before the 1 st day of the month of coverage 2. I understand if premiums are not received by the 1 st day of the month of coverage, HSA has the option of assessing a $25 late fee on the balance due. 3. I understand that if premiums are not received by the 1 st day of the month, HSA has the option of terminating coverage effective that date. 4. I certify that I have not misrepresented eligibility of an employee or misrepresented information needed to determine group size, group participation rate, or group premium rate. 5. I acknowledge that HSA is a sales and billing agent and is not responsible for payment of claims on our behalf. 6. I acknowledge that this company has fewer than 20 employees as defined in the Medicare Secondary Payer statute 42 U.S.C. 1395y. Group will immediately notify HSA if group s employee count according to Medicare Secondary Payer statute were to change so that it is no longer eligible for Medicare to be the primary payer. In the event of this change, group acknowledges that the group s Medicare eligible employees would no longer be eligible for this product. Signature (Authorized Employer Representative) Title Date
5 Fallon Companion Care Enrollment Form To enroll, please provide the following information. Group name: Group number: Administrator signature: Effective date: Last name: First name: Middle initial: q Mr. q Mrs. q Miss q Ms. Birth date: Sex: q M q F Social Security number: (optional) Home phone number: ( ) Permanent residence street address: City/town: State: ZIP code: County: Mailing address if different from above: Street address: City/town: State: ZIP code: Please provide your Medicare insurance information. Please use your Medicare card to complete this section. Medicare information: Please fill in these blanks so they match your red, white and blue Medicare card, or; Attach a copy of your Medicare card or your letter from the Social Security Administration or Railroad Retirement Board You must have Medicare Parts A and B and continue to pay your Medicare Part B premium. MEDICARE HEALTH INSURANCE MEDICARE ( ) Name of beneficiary: Sex: Medicare claim number: Is entitled to: Effective date Hospital (Part A) / / Medical (Part B) / / Please provide the following information. Name(s) of prior insurance Medical coverage: Prescription drug coverage: Fallon Health & Life Assurance Company, Inc., a wholly owned subsidiary of Fallon Community Health Plan
6 Please read this important information and then sign below. The information on this form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the state where the individual resides) on this form means that I have read and understand the contents of this form. I certify that I am eligible to receive retiree health insurance coverage from the employer named on this form. I understand how to obtain and use services under my Fallon Companion Care coverage. I certify that all information is correct to the best of my knowledge. 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 Fallon Health & Life Assurance Company, Inc. or by Medicare. X Your signature/authorized representative Date If you are the authorized representative, you must provide the following information: Name (printed) Relationship Address ( ) Phone number Need more information? To join, please call (TTY users, please call TRS Relay 711), Monday through Friday from 8:30 a.m. to 5:00 p.m. fallon health & life assurance company, inc. TM 10 Chestnut St., Worcester, MA FCHP USE ONLY q New enrollment q Age-in Name of staff member (if assisted in enrollment): Group number: Staff verification: Effective date of coverage: Rev. 05 8/11
7 It Fits! Reimbursement Form Fallon Companion Care subscribers are eligible for reimbursement once per benefit year.* Fallon Companion Care members may request up to $200 per individual contract. Requests must be made no later than three months following a benefit year. For more information about other fitness discounts, visit fchp.org. Mail completed form to: Fallon Health & Life Assurance Co. Claims Department P.O. Box Worcester, MA Subscriber information (Note: The subscriber is the primary health insurance policyholder, not necessarily the person requesting reimbursement.) Subscriber s last name First name Middle initial Address City State ZIP Subscriber s ID # (located on the front of your card) ( ) Telephone number Activity for reimbursement Type of activity Program/gym name Benefit year Amount requested Information needed for reimbursement This completed form A copy of any/all applicable health club contracts, personal fitness trainer agreements or a copy of the registration form for a town activity. These must show the beginning and ending dates of membership activity and the names of enrolled members. Dated original receipts or copies of bank/credit statements showing the charge for membership or classes (original receipts will not be returned). These should reflect the dollar amount the member is requesting. Fallon Companion Care will only reimburse for the amount reflected on these receipts/statements. When paying by check, please send a copy of the front and back of the cancelled check. Also, a brochure from the health club, facility, or program may be requested. Certification and authorization (This form must be signed and dated below by the subscriber.) Reimbursement is subject to approval by Fallon Health & Life Assurance Company. Please allow 4-6 weeks from receipt for reimbursements. Reimbursement check should be made to (check one): q Subscriber q Member Agreement: I certify that the information above is correct to the best of my knowledge. I am claiming reimbursement only for eligible expenses incurred during the applicable calendar year and for eligible members. Subscriber s signature Date fallon health & life assurance company, inc. TM
8 Fallon Companion Care No deductibles. No referrals. No worries! Fallon Companion Care is a worry-free health care coverage solution for Medicare-eligible retirees. $0 deductibles and coinsurance Fallon Companion Care pays ALL of your deductibles and coinsurance.* We make it easy, so you don t have to figure out what percentage of the bill you owe or if you ve hit your out-of-pocket maximum. Coast-to-coast coverage See a provider by your home in Shrewsbury or one near the beach in San Diego! Since Fallon Companion Care doesn t have a provider network, you can receive services from any doctor who accepts Medicare anywhere in the nation! And, if you need to see a specialist, go ahead and make an appointment! With Fallon Companion Care, you don t need a referral to see a specialist. Complete benefits Fallon Companion Care s comprehensive coverage offers more benefits than Original Medicare alone and covers costs not paid for by Medicare, including outpatient prescription drugs. Here are some examples of services you won t have to worry about paying for: Annual routine physical exam Emergency care in, and outside of, the U.S. Hospital admissions Doctor office visits Diagnostic tests including X-rays and lab services Durable medical equipment including wheelchairs and oxygen Fallon Companion Care includes the It Fits! benefit a $200 annual fitness reimbursement that members can use for anything from memberships at the gym of their choice to aerobics classes, yoga, dance lessons, weightloss programs and so much more! To learn more about Fallon Companion Care, call (TRS 711). * For services charged at the Medicare allowed amount. Fallon Companion Care is offered through Fallon Health & Life Assurance Company, Inc., a wholly owned subsidiary of Fallon Community Health Plan, Inc. All Medicare group plan enrollees must be eligible for Medicare Parts A and B by the requested effective date of coverage and must continue to pay their Medicare Part B premium. Program eligibility and benefits may vary by employer, plan and product Rev. 00 4/14 fallonhealth & life assurance company, inc.
9 hsainsurance.com Electronic Payment Request Form New clients: Use this form if you wish to authorize HSA to deduct your initial payment and/or monthly payments directly from your checking account. Client Information: Client Name: 6 Digit HSA Member #: Select payment type: First month s payment Recurring monthly payment Both first month s payment and recurring monthly payment If requesting recurring monthly payments, select date for withdrawals to start. All outstanding balances owed, including fees, will be transferred at that time. 15 th of Current Month 24 th of Current Month 15 th of Next Month 24 th of Next Month Bank Information: Bank Name: Branch: City: State: Zip: Name on Account: Routing Number: Bank Account Number: Authorization: I (we) hereby authorize HSA to initiate debit entries for my (our) checking account and the depository named above, hereinafter called DEPOSITORY, to debit the same to such account. This authorization is to remain in full force and effect until HSA has received written notification from me (us) of its termination in such time and in such manner as to afford HSA and DEPOSITORY a reasonable opportunity to act on it. Note: all written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. Authorized Signer Authorized Signer (if more than one required) Sign Name Sign Name Print Name and Title Print Name and Title Date: Client Telephone: Return Form Please fax or secure the completed form to: (781) or enrollment@hsainsurance.com For changes to existing bank information, please contact Customer Service: (781) Corporate Office: 135 Wood Rd, Braintree, MA (781) (877) (781) fax
New Case Submission Checklist Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees
hsainsurance.com New Case Submission Checklist Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees Check if Complete To ensure that your applications are processed as quickly
More informationSend all required documents (including this checklist) to:
Fallon Community Health Plan Fallon Senior Plan Premier HMO Check if Complete To ensure that your applications are processed as quickly as possible, just follow this checklist Employer completes and signs
More informationTufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees
Check if Complete Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees To ensure that your applications are processed as quickly as possible, just follow this checklist Employer
More informationSend all required documents (including this checklist) to:
Harvard Pilgrim Health Care Medicare Enhance Check if Complete To ensure that your applications are processed as quickly as possible, just follow this checklist Employer completes and signs the Master
More informationTufts Health Plan Tufts Medicare Complement (TMC) For Retirees
hsainsurance.com Tufts Health Plan Tufts Medicare Complement (TMC) For Retirees Check if Complete To ensure that your applications are processed as quickly as possible, just follow this checklist Employer
More information2018 Enrollment Election Form
2018 Enrollment Election Form Accepted 2018 Enrollment Election Form Please contact AllCare Advantage if you need information in another language or format (Braille). To Enroll in AllCare Advantage, Please
More informationEnrollment Request Form Please contact Stanford Health Care Advantage if you need information in another language or format (Braille).
Filling out and returning the enrollment request form is your first step to becoming a Stanford Health Care Advantage (HMO) member. If you and your spouse are both applying, you ll each need to fill out
More informationBlueCHiP for Medicare 2014 Individual Enrollment Request Form
BlueCHiP for Medicare 2014 Individual Enrollment Request Form Please contact BlueCHiP for Medicare if you need information in another language or format (large print). To Enroll in BlueCHiP for Medicare,
More informationBCN Advantage HMO-POS Application
BCN Advantage HMO-POS Application 2018 Employer Group/Union Enrollment Form (Coverage effective 2018) 1 Complete the following information to enroll in BCN Advantage HMO-POS. Name of employer group/union
More information2015 Medi-Pak Advantage HMO Enrollment Form Instructions
2015 Medi-Pak Advantage HMO Enrollment Form Instructions Please read first: You should use this enrollment form prior to October 15, 2014 only if you are: Requesting your enrollment be effective prior
More informationGroup Enrollment Request Form Instructions
Start here - Tear and separate pages along the perforated edge before completing Kaiser Permanente Senior Advantage (HMO) Group Enrollment Request Form Instructions Northwest Region Group Plan IMPORTANT
More informationAutomatic Payment Option Authorization Form
Automatic Payment Option Authorization Form Completed form should be mailed to: I hereby authorize Blue Cross of California, to initiate debit entries of premiums or any other related payments on my behalf
More informationHealth Net Seniority Plus (Employer HMO) Enrollment Request Form
Health Net Seniority Plus (Employer HMO) Enrollment Request Form Main subscriber ID Effective date Please contact Health Net Seniority Plus (Employer HMO) if you need information in another language or
More informationPRE-ENROLLMENT CHECKLIST
PRE-ENROLLMENT CHECKLIST Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a Medicare Specialist
More informationPRE-ENROLLMENT CHECKLIST
PRE-ENROLLMENT CHECKLIST Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a Medicare Specialist
More information5 easy steps for filling out the VNSNY CHOICE Medicare Enrollment Form
5 easy steps for filling out the Enrollment Form 1 Personal Information Section Please check the box in front of the VNSNY CHOICE Medicare option you want to enroll in. Then, provide your personal information.
More informationEnrollment Application
2014 MEDICARE ADVANTAGE Enrollment Application SelectSaver HMO-POS Optional Supplemental Dental If you have any questions, we re here to help! www.healthnowny.com/medicareoptions 1-888-989-9905 (TTY 1-877-286-5710)
More information2018 BlueCross Rx Value SM (PDP) BlueCross Rx Plus SM (PDP)
P.O. Box 100191, Columbia, SC 29202-3191 2018 BlueCross Rx Value SM (PDP) BlueCross Rx Plus SM (PDP) BlueCross Rx Value/BlueCross Rx Plus Medicare Prescription Drug Plan Individual Enrollment Form Please
More informationCity: State: Zip Code: Street Address: City: State: Zip Code:
2014 PLAN ELECTION FORM ATRIO Health Plans Marion and Polk County 2270 NW Aviation Drive, Suite 3 Roseburg, OR 97470 (541) 672-8620, (877) 672-8620 or TTY (800) 735-2900 To Enroll in ATRIO HEALTH PLANS,
More information(Please see Summary of Benefits or Evidence of Coverage for additional information on Supplemental options)
Please contact Senior Care Plus if you need information in another language or format (Braille). To Enroll in Senior Care Plus, Please Provide the Following Information: Please check which plan you want
More informationTo Enroll in a Superior Select Health Plan, Please Provide the Following Information: Please check which plan Tribute (HMO POS) SNP $0 per month
Superior Select Health Plans PO Box 3630 Little Rock, AR 72202 SuperiorSelectInc.com/Medicare Please contact Superior Select if you need information in another language or format (Braille). To Enroll in
More information2013 Individual Enrollment Request Form
BCN Advantage HMO Medicare and more Blue Care Network of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association. Please contact BCN Advantage To Enroll
More informationTo Enroll in Cigna Medicare Select Plus Rx, Please Provide the Following Information:
Cigna Medicare Select Plus Rx (HMO) Medicare Advantage Plans 2014 Enrollment Request Form Please contact Cigna Medicare Select Plus Rx if you need information in another language or format (Braille). To
More informationIndividual Enrollment Request Form
SE Please contact Network Health Medicare Advantage Plans To Enroll in a Network Health Medicare Advantage Plan, Please Provide the Following Information. Please check which plan you want to enroll in.
More informationGlobalHealth Medicare Advantage Plans
GlobalHealth Medicare Advantage Plans Individual Enrollment Request Form Please contact GlobalHealth if you need information in another language or format. To Enroll in a GlobalHealth Medicare Advantage
More informationCoverage Through Employer/Union name Grp# Last Name: First Name: Middle Initial: 9 F
PO Box 9178 Watertown, MA 02472 2019 Employer Group HMO Election Form Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille). DATE STAMP Please
More informationAAA7 Vantage Dual Special Needs (HMO SNP)
Medicare Advantage Enrollment Election Form Vantage Medicare Advantage Vantage Health Plan, Inc. 130 DeSiard Street, Suite 300 Monroe, LA 71201 (318) 361-0900 TTY (318) 361-2131 (866) 704-0109 TTY (866)
More informationENROLLMENT APPLICATION Medicare Advantage Private Fee-for-Service
Mailing Address: P.O. Box 916 Augusta, GA 30903-0916 1-877-446-7845 TTY 800-503-3118 Fax #: 803-870-8016 Hours of Operation: Monday-Sunday, 8:00 a.m. to 8:00 p.m. PLEASE COMPLETE ALL PAGES AND USE BLUE
More information5 easy steps for filling out the VNSNY CHOICE Medicare Enrollment Form
5 easy steps for filling out the VNSNY CHOICE Medicare Enrollment Form 1 2 3 4 5 Personal Information Section Please check the box in front of the VNSNY CHOICE Medicare option you want to enroll in. Then,
More informationIndividual Enrollment Request Form Please contact Denver Health Medical Plan, Inc. if you need information in another language or format (Braille).
Individual Enrollment Request Form Please contact Denver Health Medical Plan, Inc. if you need information in another language or format (Braille). To Enroll in Denver Health Medical Plan, Inc., Please
More informationMemorial Hermann Advantage (HMO)
2015 APPLICATION Memorial Hermann Advantage (HMO) Memorial Hermann Advantage (HMO) plan Individual Enrollment Form Be sure to read the important disclosures listed on the back before completing this application.
More information2019 BlueCross Rx Value SM (PDP) BlueCross Rx Plus SM (PDP)
P.O. Box 100191, Columbia, SC 29202-9954 2019 BlueCross Rx Value SM (PDP) BlueCross Rx Plus SM (PDP) BlueCross Rx Value/BlueCross Rx Plus Medicare Prescription Drug Plan Individual Enrollment Form Please
More informationEnrollment Application
2014 MEDICARE ADVANTAGE Enrollment Application Senior Blue HMO and HMO-POS Forever Blue Medicare PPO Optional Supplemental Dental If you have any questions, we re here to help! www.bsneny.com/medicare
More informationAnthem Senior Advantage (HMO) Individual Enrollment Request Form 2014
Anthem Senior Advantage (HMO) Individual Enrollment Request Form 2014 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659403, San Antonio, TX 78265-9714 or fax
More informationPlease contact CIGNA Medicare Rx (PDP) if you need information in another language or format (Braille). City: State: ZIP Code:
CIGNA Medicare Rx (PDP) Medicare Prescription Drug Plan Individual Enrollment Form Please contact CIGNA Medicare Rx (PDP) if you need information in another language or format (Braille). To Enroll in CIGNA
More informationIndividual Enrollment Request Form. Please Provide Your Medicare Insurance Information
MSA Please contact Network Health Medicare Advantage plans if you need information in another language or format (Braille). To Enroll in NetworkPrime (MSA), Please Provide the Following Information. LAST
More informationTO ENROLL IN KEYSTONE FIRST VIP CHOICE, PLEASE PROVIDE THE FOLLOWING INFORMATION Last name:
Please contact Keystone First VIP Choice (HMO SNP) if you need information in another language or format (for example, Braille). TO ENROLL IN KEYSTONE FIRST VIP CHOICE, PLEASE PROVIDE THE FOLLOWING INFORMATION
More information2018 Medicare Advantage Enrollment Request Form
2018 Medicare Advantage Enrollment Request Form Please contact Florida Hospital Care Advantage if you need information in another language or format (Braille). To Enroll in Florida Hospital Care Advantage,
More informationSelect (HMO POS) SNP $65 per month LAST Name: FIRST Name: Middle Initial: Mr. Mrs. Ms. Birth Date: Home Phone Number: ( )
Superior Select Health Plans PO Box 3630 Little Rock, AR 72202 SuperiorSelectMedicare.com Please contact Superior Select if you need information in another language or format (Braille). To Enroll in a
More informationWellCare Medicare Prescription Drug Plan 2019 Individual Enrollment Form. How to Enroll with WellCare PDP
WellCare Medicare Prescription Drug Plan 2019 Individual Enrollment Form How to Enroll with WellCare PDP 1. Please read this entire enrollment form to make sure you understand the information. An incorrect
More informationGolden State Medicare Gold (HMO)
Medicare Advantage Enrollment Form for: Golden State Medicare Gold (HMO) Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December
More informationWellCare TexanPlus HMO 2019 Employer Group Enrollment Individual Enrollment Form. How to Enroll With Our Plan
WellCare TexanPlus HMO 2019 Employer Group Enrollment Individual Enrollment Form How to Enroll With Our Plan 1. Please read this entire enrollment form to make sure you understand the information. An incorrect
More informationBlueMedicare SM Preferred (HMO) BlueMedicare SM Preferred POS (HMO POS)
P.O. Box 45296 Jacksonville, FL 32232-5296 BlueMedicare SM Preferred (HMO) BlueMedicare SM Preferred POS (HMO POS) A Medicare Advantage Health Care Plan Individual Enrollment Form Please contact BlueMedicare
More informationENROLLMENT REQUEST FORM
ENROLLMENT REQUEST FORM Please contact Affinity Health Plan if you need information in another language or format (Braille). To Enroll in Affinity Health Plan, Please Provide the Following Information:
More informationAnthem Senior Advantage (HMO) Individual Enrollment Request Form 2013
535230 29610WPSENM_subtemp Anthem Senior Advantage (HMO) Individual Enrollment Request Form 2013 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659403, San Antonio,
More informationEnrollment Form. Prominence Health Plan (HMO) Nevada Individual Enrollment Request Form
Enrollment Form Prominence Health Plan (HMO) Nevada Individual Enrollment Request Form Medicare Advantage with Prescription Drug Coverage ENROLLMENT INSTRUCTIONS The following steps must be completed to
More informationMedical Savings Account (MSA)
2014 MEDICARE ADVANTAGE Medical Savings Account (MSA) BlueSaver MSA Enrollment Application If you have any questions, we re here to help! www.bsneny.com/msa 1-877-258-SHLD (7453) (TTY 1-877-286-5710) October
More informationMedicare Advantage (MA) Individual Enrollment Request Form
Medicare Advantage (MA) Individual Enrollment Request Form Please contact CareMore Health Plan if you need information in another language or format (Braille). To enroll in CareMore Health Plan, please
More informationAnthem MediBlue Dual Advantage (HMO SNP) Individual Enrollment Request Form 2016
Anthem MediBlue Dual Advantage (HMO SNP) Individual Enrollment Request Form 2016 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659404, San Antonio, TX 78265-9863
More information2017 Medicare Advantage Prescription Drug Plan (MAPD) Individual Enrollment Form
2017 Medicare Advantage Prescription Drug Plan (MAPD) Individual Enrollment Form Please contact SummaCare if you need information in a different format. To enroll in SummaCare, please provide the following
More informationIf you also want to enroll in a Dental Plan, please check the plan you want to enroll in:
Medicare Advantage HMO Individual Enrollment Request Form HMO Health Alliance Plan 2850 W. Grand Blvd., Detroit, MI 48202 Telephone (800) 868-3153 TTY: 711 Please contact HAP Senior Plus (HMO) if you need
More informationPlease contact Sharp Health Plan if you need information in another language or format (Braille).
2019 Sharp Direct Advantage SM Basic (HMO) & Sharp Direct Advantage SM Premium (HMO) Enrollment Form Completing your enrollment is your first step to becoming a Sharp Direct Advantage Medicare member.
More informationIndividual Enrollment Request Form
Please contact FirstCare Advantage (HMO) if you need information in another language or format (Braille). To Enroll in FirstCare Advantage (HMO), Please Provide the Following Information: Please check
More informationRiverSpring Star (HMO SNP) Enrollment Request Form
RiverSpring Star (HMO SNP) Enrollment Request Form Please contact RiverSpring (HMO SNP) if you need information in another language or format (Braille). To Enroll in RiverSpring Star (HMO SNP), Please
More informationMedicare Advantage Individual
Medicare Advantage Individual Enrollment Election Form Please contact Care1st Health Plan if you need information in another language or format (Braille). To Enroll in Care1st Health Plan, Please Provide
More informationMedBlue sm Rx (PDP) MedBlue sm Rx Plus (PDP)
MedBlue sm Rx (PDP) MedBlue sm Rx Plus (PDP) P.O. Box 100191, Columbia, SC 29202-3191 Medicare Prescription Drug Plan Individual Enrollment Form Please contact MedBlue Rx or MedBlue Rx Plus if you need
More informationAnthem MediBlue (HMO) Individual Enrollment Request Form 2016
Anthem MediBlue (HMO) Individual Enrollment Request Form 2016 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659404, San Antonio, TX 78265-9863 or fax the completed
More information2019 Medicare Advantage Enrollment Form
Arizona 2019 Medicare Advantage Enrollment Form Please contact Bright Health at 844-667-5502 (TTY: 711) if you need information in another language or format (Braille). To Enroll in Bright Health Please
More informationIndividual Enrollment Request Form Instructions
Start here - Tear and separate pages along the perforated edge before completing Kaiser Permanente Senior Advantage (HMO) Individual Enrollment Request Form Instructions Hawaii - Big Island Region Individual
More informationINSTRUCTIONS for COMPLETING Optima Community Complete (HMO SNP) Enrollment Request Form
INSTRUCTIONS for COMPLETING Optima Community Complete (HMO SNP) Enrollment Request Form IMPORTANT: Please PRINT information in pen and DO NOT SKIP any steps. Fill all information in as completely as possible.
More informationWellCare Medicare Prescription Drug Plan 2018 Individual Enrollment Form
WellCare Medicare Prescription Drug Plan 2018 Individual Enrollment Form How to Enroll with WellCare (PDP) 1 Please read this entire enrollment form to make sure you understand the information. 2 When
More information2015 Enrollment Form. H5471_SHPE02R2067 Approved 9/18/2014. White Copy Enrollment Yellow Copy Agent Pink Copy Member
2015 Enrollment Form White Copy Enrollment Yellow Copy Agent Pink Copy Member Please Read This Important Information If you currently have health coverage from an employer or union, joining Simply Healthcare
More informationEASY CHOICE MEDICARE ADVANTAGE PLANS
EASY CHOICE MEDICARE ADVANTAGE PLANS 2017 INDIVIDUAL ENROLLMENT FORM 1 2 3 4 5 How to Enroll with Easy Choice Please read this entire enrollment form to make sure you understand the information. When you
More informationBCBSHP MediBlue Dual Advantage (HMO SNP)
BCBSHP MediBlue Dual Advantage (HMO SNP) Individual Enrollment Request Form 2017 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659404 San Antonio TX, 78265-9863
More informationEnrollment Request Form Instructions 2018 Plan Year
Enrollment Request Form Instructions 2018 Plan Year Please read before completing your enrollment request form. You are eligible to join Care N Care Health Plan(s) PPO if: You are entitled to Medicare
More informationTo Enroll in BlueCare Plus (HMO SNP) Please Provide the Following Information: Phone Number: ( ) City: County: State: ZIP Code:
2018 BlueCare Plus (HMO SNP) SM Enrollment Request Form Please contact BlueCare Plus (HMO SNP) if you need information in another language or format (Braille). To Enroll in BlueCare Plus (HMO SNP) Please
More informationIndividual Enrollment Request Form
Individual Enrollment Request Form 3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806 Please contact SCAN Health Plan if you need information in another language or format (Braille). To enroll in
More informationTo enroll in Vantage Medicare Advantage, please provide the following information:
Medicare Advantage Enrollment Election Form Vantage Medicare Advantage Vantage Health Plan, Inc. 130 DeSiard Street, Suite 300 Monroe, LA 71201 (318) 361-0900 TTY (318) 361-2131 (866) 704-0109 TTY (866)
More informationEnrollment Request Form Instructions 2019 Plan Year
Enrollment Request Form Instructions 2019 Plan Year Please read before completing your enrollment request form. You are eligible to join Teal Premier Health Plan(s) PPO if: You are entitled to Medicare
More informationVantage 100 (HMO-POS) $ per month
2019 Medicare Advantage Enrollment Election Form Vantage Medicare Advantage Vantage Health Plan, Inc. 130 DeSiard Street, Suite 300 Monroe, LA 71201 (318) 361-0900 TTY (318) 361-2131 (866) 704-0109 TTY
More informationIndividual Enrollment Request Form
Individual Enrollment Request Form To enroll in VillageHealth, please provide the following information: Please check which plan you want to enroll in: o 001 VillageHealth (HMO-POS SNP) Riverside and San
More informationTo Enroll in Optima Medicare HMO, Please Provide the Following Information: Optima Medicare Prime (HMO) $ 85 premium per month
2019 Optima Medicare HMO Enrollment Request Form Contact Optima Medicare at 1-855-547-7740 (TTY Call 711) if you need information in another format or language. Our office hours are 8 a.m. 8 p.m., 7 days
More informationIndividual Enrollment Request Form
Individual Enrollment Request Form 3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806 Please contact SCAN Health Plan if you need information in another language or format (Braille). To enroll in
More information2019 BlueCross Secure SM (HMO) Individual Enrollment Request Form
P.O. Box 100191, Columbia, SC 29202-9954 2019 BlueCross Secure SM (HMO) Individual Enrollment Request Form Please contact BlueCross BlueShield of South Carolina if you need information in another language
More information2018 BlueCross Total SM (PPO) Individual Enrollment Request Form
P.O. Box 100191, Columbia, SC 29202-3191 2018 BlueCross Total SM (PPO) Individual Enrollment Request Form Please contact BlueCross BlueShield of South Carolina if you need information in another language
More informationAlternate Phone Number: ( ) Address: Sex: 9 M ( ) 9 F. Permanent Residence Address (P.O. Box is not allowed): City: State: Zip Code:
PO Box 9178 Watertown, MA 02472 2018 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
More informationEnrollment Request Form Instructions 2018 Plan Year
Enrollment Request Form Instructions 2018 Plan Year Please read before completing your enrollment request form. You are eligible to join HealthTeam Advantage Health Plan(s) PPO if: You are entitled to
More informationAnthem MediBlue Dual Advantage (HMO SNP)
Anthem MediBlue Dual Advantage (HMO SNP) Individual Enrollment Request Form 2018 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659403 San Antonio TX, 78265-9714
More informationMedicare Advantage Individual
Medicare Advantage Individual Enrollment Election Form Please contact Care1st if you need information in another language or format (Braille). To Enroll in Care1st, Please Provide the Following Information:
More informationBCBSHP MediBlue (HMO) Individual Enrollment Request Form 2017
BCBSHP MediBlue (HMO) Individual Enrollment Request Form 2017 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659404 San Antonio TX, 78265-9863 or fax the completed
More informationAnthem Medicare Preferred Standard (PPO) Individual Enrollment Request Form 2013
535230 29610WPSENM_subtemp Anthem Medicare Preferred Standard (PPO) Individual Enrollment Request Form 2013 Be sure to complete the entire enrollment form. Then, mail the completed form to P.O. Box 659404,
More information2018 Medicare Enrollment
2018 Medicare Enrollment Please mail or fax your enrollment form to the Optima Medicare HMO enrollment center at: Optima Medicare 3535 Piedmont Rd NE Suite 1400 Atlanta GA 30305-1518 Fax Number (Toll-Free)
More information9 HMO Basic Rx $23.00 per month 9 HMO Value Rx $54.00 per month 9 HMO Prime Rx $79.00 per month 9 HMO Prime Rx Plus $99.
PO Box 9178 Watertown, MA 02472 2019 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
More informationMEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM
MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Please contact Care1st if you need information in another language or format (Braille). To Enroll in Care1st, Please Provide the Following Information:
More informationGroup Election Request Form
Start here - Tear and separate pages along the perforated edge before completing Kaiser Permanente Senior Advantage (HMO) Group Election Request Form Northern California or Southern California Region Group
More information2018 Individual Enrollment Request Form Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Choice Plan (HMO) and Blue Shield Trio Medicare (HMO)
2018 Individual Enrollment Request Form Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Choice Plan (HMO) and Blue Shield Trio Medicare (HMO) Please contact Blue Shield of California if you need information
More information$0 per month q AZ, Pima County. q CA, Los Angeles/Orange Counties $0 per month q CA, Los Angeles/Orange Counties $0 per month.
Medicare Advantage (MA) Individual Enrollment Request Form Please contact CareMore Health Plan if you need information in another language or format (Braille). To enroll in CareMore Health Plan, please
More informationPlease Provide Your Medicare Insurance Information
Please contact Memorial Hermann Advantage HMO if you need information in another language or format (Braille). To Enroll in Memorial Hermann Advantage HMO, Please Provide the Following Information: Please
More informationPriority Health Medicare
Priority Health Medicare To enroll online please visit our website at prioritymedicare.com Enrollment instructions To avoid delays in processing your enrollment, please follow these helpful tips. Make
More informationINDIVIDUAL ENROLLMENT REQUEST FORM INSTRUCTIONS
Start here - Tear and separate pages along the perforated edge before completing Kaiser Permanente Senior Advantage (HMO) INDIVIDUAL ENROLLMENT REQUEST FORM INSTRUCTIONS Hawaii - Oahu/Maui Region Individual
More informationGlobalHealth Medicare Advantage Plans
GlobalHealth Medicare Advantage Plans Individual Enrollment Request Form (For New Members Only) Attestation of Eligibility for an Enrollment Period Typically, you may enroll in a Medicare Advantage plan
More informationPlease select a premium payment option: Get a bill
CHRISTUS Health Plan Generations Enrollment Application Please check the plan that you want: CHRISTUS Health Plan Generations (HMO) Plan 003 ($0 monthly premium) CHRISTUS Health Plan Generations Plus (HMO)
More informationHealth Choice Generations HMO SNP 410 North 44th Street, Suite 510 Phoenix, AZ TTY: 711
Health Choice Generations HMO SNP 410 North 44th Street, Suite 510 Phoenix, AZ 85008 1-800-656-8991 TTY: 711 www.healthchoicegenerations.com IMPORTANT Before you fill out each form, please insert the enclosed
More informationGolden State Medicare Health Plan
Medicare Advantage Enrollment Form for: Golden State Medicare Health Plan Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December
More informationWellCare 2019 Private Fee-for-Service Plan Individual Enrollment Form. How to Enroll with WellCare Private Fee-for-Service Plan
WellCare 2019 Private Fee-for-Service Plan Individual Enrollment Form How to Enroll with WellCare Private Fee-for-Service Plan 1. Please read this entire enrollment form to make sure you understand the
More informationDeductibles Making them as easy as 1, 2, 3.
Deductibles Making them as easy as 1, 2, 3. Developed for you by Fallon Community Health Plan When you sign up for health insurance, you are given a lot of information about the plan and its terms. All
More informationSacramento* County ($0 per month) Choice Plan (Los Angeles*/Orange counties)
2015 Individual Enrollment Request Form Blue Shield 65 Plus (HMO) and Blue Shield 65 Plus Choice Plan (HMO) Please contact Blue Shield of California if you need information in another language or format
More informationPlease Provide Your Medicare Insurance Information
Please contact Healthy Advantage HMO SNP or Healthy Advantage Plus HMO if you need information in another language or format (Braille). To Enroll in Molina Healthcare, Please Provide the Following Information:
More informationBlue MedicareRx (PDP) Medicare Prescription Drug Plan Individual Enrollment Form 2011
Blue MedicareRx (PDP) Medicare Prescription Drug Plan Individual Enrollment Form 2011 Be sure to complete the entire enrollment form. Then, mail the completed form to Enrollment Processing Center, PO Box
More information2017 Individual Enrollment Form
2017 Individual Enrollment Form Easy ways to enroll Enroll online at BasicBlueRx.com Call 1-844-469-2920, 8 a.m. to 8 p.m., daily, local time (TTY hearing impaired users call 711) Contact your licensed
More information