Please fill in the “subscriber” sections of this
membership application completely so we do not
delay enrollment. You will receive your Tufts Health
Plan ID card and member benefit document soon.
Employer Section
Your employer must fill out this section.
Employee Section
• Personal Information: Complete all enrollment
information. Please select a primary care provider
(PCP). Be sure to fill out this section for all
members, including dependents.
• Product Code: Please be sure to fill in the correct
product code for the plan you have selected.
(Please use chart on the right.)
• Primary Care Provider: If your plan requires you
to choose a PCP, it is important that you select
one right away. Until we know who your PCP
is, your in-network benefits may be limited to
emergency services only. To find a PCP, visit
tuftshealthplan.com and use the Doctor Search
feature. On this application, indicate whether
you are a current patient of the PCP you have
listed. (You are a current patient if you have
routinely received health care services from
this provider in the past.) If you are selecting
a new PCP, contact the provider’s office right
away and introduce yourself as a new Tufts
Health Plan member. Ask if they are taking
new patients and if the provider would like to
schedule a physical exam.
• Other Health Coverage: If you have other or
additional insurance (such as Medicare), please
check the correct box and fill in the requested
information. If you do not have any other
insurance, be sure to check the “No” box.
When the Application is Complete
• Give the application to your employer.
• Employer mails the form to:
Tufts Health Plan
P.O. Box 9186
Watertown, MA 02471-9186
Notices
By enrolling, you understand and agree that if you or any of your
enrolled dependents obtain a health care benefit or payment that
you are not entitled to receive, or if you knowingly present a claim
that contains a false statement, you may lose your health care
coverage and can be liable for the full amount of the health care
benefit or payment made and for reasonable attorney’s fees and
costs, including the cost of the investigation.
Tufts Health Plan arranges for the provision of health care services
through agreements with independent community-based health
care professionals working in private offices and with hospitals
throughout the Tufts Health Plan service area. These providers
are independent contractors and not employees, agents, or
representatives of Tufts Health Plan. Tufts Health Plan does not
directly provide health care services.
We collect email addresses and cell phone numbers (“your informa-
tion”) as part of the registration process. We may use your information
to notify you of online activity related to the security and privacy of
your accounts, such as, retrievals of username, etc. In addition we may
use your information to send you health and wellness information and
other updates that might be of interest to you as members of Tufts
Health Plan. On certain occasions we may also share your information
with providers in our network so that they may send you information
that describes health-related products and/or services offered by the
provider and included in your plan of benefits, enhancements to your
plan, and/or benefits and services available to you as a health plan
member that add value to, but are not part of, your plan of benefits.
Each time we or any such provider sends health and wellness informa-
tion and other updates, you will be given the opportunity to opt-out
of receiving similar emails or cell phone communications in the future.
Please note that you cannot opt-out of receiving emails that notify you
of online activity since these are necessary to protect the privacy and
security of Web accounts.
A. HMO Premium
B. HMO Value
C. HMO Basic
D. HMO Choice
Copay
E. Advantage HMO
F. Advantage HMO
Saver
G. POS
H. POS Choice
Copay
I. EPO
J. EPO Choice
Copay
K. PPO
L. Advantage PPO
M. Advantage PPO
Saver
N. Navigator by Tufts
Health Plan
O. CareLink
P. Select HMO
Q. Select Advantage
HMO
R. Rhode Island
HEALTHPact
S. Your Choice HMO
T. Your Choice PPO
U. Steward Community
Choice
LPC. Lifespan Premier
Choice
18079
Need Help?
If you need assistance
selecting a PCP, visit
tuftshealthplan.com and
use the Doctor Search
feature. If you need
help filling out this form,
call a Member Services
Representative.
Member Services:
800.462.0224
Product Codes
Write the corresponding letter in the product
box in the subscriber section of the enrollment
application.
WELCOME TO TUFTS HEALTH PLAN
COM-30100003-201911
We speak over 200 languages.
Call Member Services.
