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 Advantage Plan (Part C)
Who can use this form?
People with Medicare who want to join a
Medicare Advantage 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 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.
Y0026_201340_C Approved 8/21/2020
OMB No. 0938-1378
Expires: 7/31/2023
White - Enrollment Yellow - Member Page 1 of 3
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 Advantage plans
available to you, please refer to the Summary of Benefits. Please check which plan you want to enroll in:
EmblemHealth
VIP Dual (HMO D-SNP)
EmblemHealth
VIP Dual Select
(HMO D-SNP)
EmblemHealth
VIP Dual Reserve
(HMO D-SNP)
EmblemHealth
VIP Solutions
(HMO D-SNP)
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: ______________________________________________________
Y0026_201340_C Approved 8/21/2020
86-9380-21 8/20
Print
Clear
White - Enrollment Yellow - Member Page 2 of 3
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
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: ( _____ ) ________- ___________
–––––––––––––––––––––––––––––––––––––––––––––
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.
IMPORTANT: Please Read and Sign Below
• I must keep both Hospital (Part A) and Medical (Part B) to stay in EmblemHealth Medicare Advantage Plans.
• By joining this Medicare Advantage Plan, I acknowledge that EmblemHealth Medicare will share my information with
Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that
authorize the collection of this information (see Privacy Act Statement below).
• Y our response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
•
The information on this enrollment 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 people with Medicare are generally not covered under Medicare while out of the country , except for
limited coverage near the U.S. border.
• I understand that when my EmblemHealth Medicare coverage begins, I must get all of my medical and prescription drug
benefits from EmblemHealth Medicare. Benefits and services provided by EmblemHealth Medicare and contained in my
EmblemHealth Medicare “Evidence of Coverage” document (also known as a member contract or subscriber agreement)
will be covered. Neither Medicare nor EmblemHealth Medicare will pay for benefits or services that are not covered.
• I understand that the phone numbers and/or email I provided on this application may be used by EmblemHealth or any of its
contracted parties to contact me about my account, my health benefit plan or related programs, or services provided to me.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application
means that I have read and understand the contents of this application. If signed by an authorized representative (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 Medicare.
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 Advantage plan only during the Annual Enrollment Period from October 15
through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage Plan
outside of this 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 enrolled in a Special Needs Plan (SNP) but I
have lost the special needs qualification required to
be in that plan. I was disenrolled from the SNP 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) Plans, improve care, and for the payment of Medicare
benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and422.60 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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