Fillable Optional Supplemental Benefit Enrollment/Disenrollment Form (John Hopkins Medicine Medicare Plan)

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Optional Supplemental Benefit Enrollment/Disenrollment Form (John Hopkins Medicine Medicare Plan)

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The Optional Supplemental Benefit Enrollment/Disenrollment Form (John Hopkins Medicine Medicare Plan) form is 2 pages long and contains:

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  • 9 check-boxes
  • 14 other fields

Country of origin: US
File type: PDF

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Optional Supplemental Benefit Enrollment/Disenrollment Form
I am a current member of Johns Hopkins Advantage MD (HMO)/(PPO) and wish to
add/remove the optional supplemental benefit.
Last Name: First Name: Middle Initial: Mr. Mrs. Miss Ms.
Medicare#
Birth Date: Sex:
Male Female
Phone Number:
( )
.
Please carefully read and complete the following information before signing and dating.
Adding Optional Supplemental Coverage
I am a current member of Johns Hopkins Advantage MD (PPO)/(HMO). I wish to add
optional supplemental coverage to my current plan. My new monthly premium will be:
Johns Hopkins Advantage MD (HMO) (Baltimore City residents only) $50 per month
Johns Hopkins Advantage MD (HMO) $70 per month
Johns Hopkins Advantage MD (PPO) $121 per month
Johns Hopkins Advantage MD Plus (PPO) $149 per month
Removing Optional Supplemental Coverage
I am a current member of Johns Hopkins Advantage MD. I wish to remove optional
supplemental coverage from my current plan.
Supplemental Benefit Purchase Options
• Advantage MD (PPO) and Advantage MD (HMO)
For an extra $30 per month, members can purchase an optional supplemental package that
includes both comprehensive dental and fitness benefits. The dental and fitness benefits
cannot be purchased separately.
• Advantage MD Plus (PPO)
For an extra $28 per month, members can purchase the supplemental comprehensive dental
benefit. The fitness benefit is automatically included in the Advantage MD Plus plan at no
additional cost.
I have carefully read and understand that:
1. My monthly premium will increase/decrease by adding/removing optional
supplemental dental coverage to/from my current plan.
2. The above stated premium amounts do not include any Medicare late enrollment
penalties for which I may be currently responsible.
3. My current premium payment method will remain the same.
Signature*: ______________________________ Date: _____________
*Or the signature of the person authorized to act on your behalf under the laws of the State where
you live. If signed by an authorized individual (as described above), this signature certifies that:
1) this person is authorized under State law to complete this disenrollment and 2) documentation
of this authority is available upon request by Johns Hopkins Advantage MD or by Medicare.
If you are the authorized representative, you must provide the following information:
Name : _________________________________
Address: _______________________________________________
Phone Number: (_____) ______- __________________
Relationship to Enrollee ______________________________
Please mail or fax the completed form to Johns Hopkins Advantage MD P.O. Box 3538
Scranton, PA 18505, fax: 855-206-9203. If you have questions about this form or need more
information, please contact Customer Service at 1-877-293-5325 (TTY 711), Oct. 1 through
March 31 - Monday through Sunday, 8 a.m. to 8 p.m. and April 1 through Sept. 30 - Monday
through Friday, 8 a.m. to 8 p.m.
Y0124_DentalOptIn0
720_C
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Optional Supplemental Benefit EnrollmentDisenrollment Form (John Hopkins Medicine Medicare Plan)

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Completed 25 May 2021

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