OMB No. 0938-1378
2021 Johns Hopkins Advantage MD (HMO and PPO)
Enrollment Request Form
Who can use this form?
People with Medicare who want to join a Medicare
Advantage Plan or Medicare Prescription Drug Plan
To join a plan, you must:
• Be a United States citizen or be lawfully present
in the U.S.
• Live in the plan’s service area
Important: To join a Medicare Advantage Plan,
you must also have both:
• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
When do I use this form?
You can join a plan:
• Between October 15–December 7 each year (for
coverage starting January 1)
• Within 3 months of rst getting Medicare
• In certain situations where you’re allowed to join
or switch plans
Visit Medicare.gov to learn more about when you
can sign up for a plan.
What do I need to complete this form?
• Your Medicare Number (the number on your
red, white, and blue Medicare card)
• Your permanent address and phone number
Note: You must complete all items in Section 1.
The items in Section 2 are optional — you can’t be
denied coverage because you don’t ll them out.
• If you want to join a plan during fall open
enrollment (October 15–December 7), the plan
must get your completed form by December 7.
• Your plan will send you a bill for the plan’s
premium. You can choose to sign up to have
your premium payments deducted from your
bank account or your monthly Social Security
(or Railroad Retirement Board) benefit.
What happens next?
Send your completed and signed form to:
Johns Hopkins Advantage MD
P.O. Box 3538
Scranton, PA 18505
Once they process your request to join, they’ll
How do I get help with this form?
Call Johns Hopkins Advantage MD at
1-888-403-7662. TTY users can call 711.
Or, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048 24 hours a day/7 days a week.
En español: Llame a Johns Hopkins Advantage MD al
1-888-403-7662/TTY 711 o a Medicare gratis al 1-800-
633-4227 y oprima el 2 para asistencia en español y un
representante estará disponible para asistirle 24 horas
del día, los 7 días de la semana.
White – Enrollment Copy
Pink – Customer Copy
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless
it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time
required to complete this information is estimated to average 20 minutes per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have any comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
IMPORTANT Do not send this form or any items with your personal information (such as claims, payments, medical
records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its
collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan.
See “What happens next?” on this page to send your completed form to the plan.