Fillable Individual Enrollment Request Form to Enroll in a (EmblemHealth)

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Individual Enrollment Request Form to Enroll in a (EmblemHealth)

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Individual Enrollment Request Form to Enroll in a Medicare
Prescription Drug Plan (Part D)
Who can use this form?
People with Medicare who want to join a
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 Prescription Drug
Plan, you must also have either, or 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 January1)
• Within 3 months of first 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
fill them out.
Reminders:
• 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:
Emblemhealth Medicare
PO BOX 4001
Farmington CT 06034-9900
Once they process your request to join,
they’ll contact you.
How do I get help with this form?
Call EmblemHealth at 800-447-9169.
TTY users can call 711.
Or, call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users can call
1-877-486-2048.
En español: Llame a EmblemHealth al
800-447-5496/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.
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 estimate(s) 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.
S5966_201343_C Approved 8/21/2020
OMB No. 0938-1378
Expires: 7/31/2023
White - Enrollment Yellow - Member Page 1 of 3
EmblemHealth Medicare Prescription Drug Plan Individual Enrollment Form
Please contact EmblemHealth if you need information in another language or format.
Section 1 - To Enroll, Please Provide the Following Information:
Note to Applicant: For information about service area and premiums of EmblemHealth Medicare Prescription Drug Plans
available to you, please refer to the Summary of Benefits. Please check which plan you want to enroll in:
EmblemHealth VIP Rx (PDP) EmblemHealth VIP Rx Plus (PDP)
LAST Name: FIRST Name: M.I.:
Mr. Mrs. Ms.
Birth Date:
____/____/_______
Sex:
M F
Home Phone Number:
( )_____-_______
Cell Phone Number:
( )_____-________
Email Address: Contact Preference:
Mail Email Text Phone
Permanent Residence Street Address (No PO Box):
City: State: ZIP Code:
Mailing Address (only if different from above):
City: State: ZIP Code:
Emergency Contact: Phone Number: Relationship to You:
Medicare Number _____________________________________ Part A ___/____/______ Part B ___/____/______
Will you have other prescription drug coverage in addition to this plan? Yes No
Name of other coverage: ID # for this coverage: Group # for this coverage:
_________________________ _________________________ _________________________
Are you enrolled in your State Medicaid program? *(Required for enrollment in SNP Plans)
Yes No
If “yes,” please provide your Medicaid number: _______________________________________________________
S5966_201343_C Approved 8/21/2020
86-9908-21 8/20
Print
Clear
White - Enrollment Yellow - Member Page 2 of 3
Please Read and Sign Below
• I must keep Part A or Part B to stay in EmblemHealth
• I understand that the phone numbers and/or email
Medicare Prescription Drug Plans.
I provided on this application may be used by
• By joining this Medicare Prescription Drug Plan, I
EmblemHealth or any of its contracted parties to
acknowledge that EmblemHealth Medicare will release
contact me about my account, my health benefit plan or
my information to Medicare, who may use it to track
related programs, or services provided to me.
beneficiary enrollment, for payment and other purposes
• I understand that my signature (or the signature of the
applicable to Federal statutes that authorize the collection
person legally authorized to act on my behalf) on this
of this information (see Privacy Act Statement below).
application means that I have read and understand the
• Your response to this form is voluntary. However, failure to
contents of this application. If signed by an authorized
respond may affect enrollment in the plan.
representative (as described above), this signature
certifies that:
• The information on this enrollment form is correct to the
best of my knowledge. I understand that if I intentionally
1) This person is authorized under State law to
provide false information on this form, I will be disenrolled
complete this enrollment, and
from the plan.
2) Documentation of this authority is available upon
• I understand that people with Medicare are generally not
request by Medicare.
covered under Medicare while out of the country, except
for limited coverage near the U.S. border.
Your Signature:
Proposed Effective Date: Today’s Date:
If you are the authorized representative, you must sign above and provide the following information:
Name:
Relationship to Enrollee:
Address: _____________________________________ Phone Number: ( _____ ) ________- ___________
–––––––––––––––––––––––––––––––––––––––––––––
Section 2
You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by
mail or visit emblemhealth.com/medicare for additional payment options. You can also choose to pay your premium by
automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you pay a
Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be
responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from
your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay EmblemHealth the Part D-IRMAA.
Would you like the premium for this plan deducted from your SSA or RRB monthly benefit check?
Yes
No
I get monthly benefits from:
Social Security
RRB
Please choose the name of a Primary Care Physician (PCP) from our Provider Directory.
Name ____________________________ PCP #______________
Current Patient
Please check one of the boxes below if you would prefer us to send you information in a language other than
English or in an accessible format:
Spanish Chinese Large Print
Please contact EmblemHealth at 800-447-9169, TTY: 711, 8 am to 8 pm, seven days a week from October 1 to
March 31 and 8 am to 8 pm, Monday to Friday from April 1 to September 30, if you need information in an
accessible format or language, other than what is listed above.
White - Enrollment Yellow - Member Page 3 of 3
Please Complete This Section To Help Determine Which Election Period You Qualify For
Typically, you may enroll in a Medicare Prescription Drug Plan only during the Annual Enrollment Period from
October 15 through December 7 of each year. Additionally, there are exceptions that may allow you to enroll in a
Medicare Prescription Drug Plan outside of the annual enrollment period.
Please read the following statements carefully and please check the box if the statement applies to you. By checking
any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period.
If we later determine that this information is incorrect, you may be disenrolled.
I am enrolling during the Annual Enrollment Period
(AEP) from October 15 to December 7.
I am new to Medicare.
I am enrolled in a Medicare Advantage plan and want
to make a change during the Medicare Advantage
Open Enrollment Period (MA OEP).
I recently moved outside of the service area for my
current plan or I recently moved and this plan is a new
option for me. I moved on ______/______/______.
I recently was released from incarceration. I was
released on ______/______/______.
I recently returned to the United States after living
permanently outside of the U.S. I returned to the U.S. on
______/______/______ .
I recently obtained lawful presence status in the United
States. I got this status on ______/______/______.
I recently had a change in my Medicaid (newly got
Medicaid, had a change in level of Medicaid assistance,
or lost Medicaid) on ______/______/______.
I recently had a change in my Extra Help paying for
Medicare prescription drug coverage (newly got Extra
Help, had a change in the level of Extra Help, or lost
Extra Help) on ______/______/______.
I have both Medicare and Medicaid (or my state helps
pay for my Medicare premiums) or I get Extra Help
paying for my Medicare prescription drug coverage,
but I haven’t had a change.
I am moving into, live in, or recently moved out of a
Long Term Care Facility (for example, a nursing home or
long-term care facility). I moved/will move into/out of
the facility on______/______/______.
I recently left a PACE program on
______/______/______.
I recently involuntarily lost my creditable prescription
drug coverage (coverage as good as Medicare’s).
I lost my drug coverage on ______/______/______.
I am leaving employer or union coverage on
______/______/______.
I belong to a pharmacy assistance program provided
by my state.
My plan is ending its contract with Medicare, or
Medicare is ending its contract with my plan.
I was enrolled in a plan by Medicare (or my state) and
I want to choose a different plan. My enrollment in that
plan started on ______/______/______.
I was affected by a weather-related emergency or
major disaster (as declared by the Federal Emergency
Management Agency (FEMA). One of the other
statements here applied to me, but I was unable to
make my enrollment because of the natural disaster.
None of these statements apply to me.
If none of these statements apply to you or you’re not sure,
please contact EmblemHealth at 800-447-9169, TTY: 711,
8 am to 8 pm, 7 days a week from October 1 to March 31
and 8 am to 8 pm, Monday to Friday from April 1 to
September 30, to see if you are eligible to enroll.
For Company Use Only
Staff Member/Agent/Broker Signature: _______________________________ Agent/Broker ID#: ________________
Date Accepted: _______________ Source Code: _____________________ Location: _________________________
Election Period: ICEP/IEP: ____________ AEP: ___________ SEP (type): _____________
Scope of Appointment (required if not seminar):
Yes Seminar No Seminar
PRIVACY ACT STATEMENT: The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans
to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the
payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50, 422.60, 423.30 and
423.32 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare
beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”,
System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
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Individual Enrollment Request Form to Enroll in a (EmblemHealth)

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Completed 1 August 2021

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