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.
Group/Company Name________________________________________________________________________ Group Number_______________________________________________________
Office Location________________________________________ Date of Hire____________________________________ Effective Date of Coverage____________________________________
Type of Enrollment: New Hire Open Enrollment COBRA New Group Qualifying Event (MUST specify)___________________ Qualifying Event Date______________________________
Last Name_____________________________________________________________________ First Name__________________________________________________________________ Middle Initial___________
Employee Social Security Number (required)___________________________________________ Date of Birth (MM/DD/YYYY)___________ / ___________ / _________________ Gender: Male Female
Residential Address (required) ____________________________________________________________________ City_____________________________________ State________ ZIP_________________________
P.O. Box (optional) __________________________________________________________ City_____________________________________ State________ ZIP_____________________
Email Address _____________________________________________ Home/Work Telephone ( _____ ) _________________ Cell Phone ( _____ ) _________________Primary Language_______________________
Marital Status: Single Married Divorced
Domestic Partner Type of Coverage Requested: Individual Family Other______________________
Primary Care Provider First Name___________________________________ Last Name___________________________________ PCP/ NPI # ____________________________________
Sex
M/F
Date of Birth
(MM/DD/YEAR)
Social Security Number
(required for all members)
Choose a Primary Care
Provider for each member
(Include first and last
name.)
Check if
currently
used for
primary care PCP NPI #
Spouse
Domestic Partner
- -
Child/Dependent
- -
Child/Dependent
- -
Child/Dependent
- -
Child/Dependent
- -
Child/Dependent
- -
Please check if you are using additional membership applications for additional dependent children.
Do you or someone else covered under this insurance policy have other health insurance coverage at the same time your Tufts Health Plan policy is in effect? Yes Yes (Medicare) No
Name of Health Plan_________________________________________ Name of Plan Holder________________________________ Health Plan Number____________________ Effective Date______________________
Names of Family Members Covered___________________________________ Is Spouse Employed? Yes No If Yes, Name and Address of Employer _________________________________________________
EMPLOYER SECTION
MEMBER ENROLLMENT FORM
Please print clearly or type. Please be sure application is completed in full to ensure enrollment. Employers can mail completed forms to: Tufts Health Plan • P.O. Box 9186 • Watertown, MA 02471-9186
SUBSCRIBER SECTION PRODUCT (Select corresponding letter from the list on the front page) _________ Other _______________________________________
- -
FAILURE TO COMPLETE FORM WILL CAUSE A DELAY IN ENROLLMENT.
The information supplied on this form is true and complete. I authorize my employer to make necessary payroll deductions, if any, for my share of Tufts Health Plan coverage. I assign benefits to Tufts Health Plan providers, which
means that Tufts Health Plan is authorized to make payments directly to Tufts Health Plan providers for services rendered to me (us). I grant Tufts Health Plan any legal right that I (we) may have to recover the cost of services for
an illness or injury caused by someone else when these services have been or will be paid by Tufts Health Plan. I understand that calls to the Member Services department may be monitored for quality assurance. I understand that
the benefits for which I (we) are eligible are those described in the applicable member benefit documents.
Subscriber Signature__________________________________ Date_______________ Employer Signature (required)____________________________ Telephone_______________________ Date______________
First Name / Last Name (if dierent)
PLEASE WRITE IN YOUR 8 DIGIT GROUP NUMBER BELOW
Members Enrolling
Is this your current PCP?
Yes No
SVRHT - TOWN OF EAST LONGMEADOW
16209-301
click to sign
signature
click to edit
click to sign
signature
click to edit
List-Languages-THP-ID-07/16
For no cost translation in English, call the number on your ID card.
Arabic .ﻚﺑ ﺔﺻﺎﺨﻟا ﺔﯾﻮﮭﻟا ﺔﻗﺎﻄﺑ ﻰﻠﻋ نوﺪﻤﻟا ﻢﺮﻟا ﻰﻠﻋ لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ﺔﯿﺑﺮﻌﻟا ﺔﻐﻠﻟﺎﺑ ﺔﯿﻧﺎﺠﻤﻟا ﺔﻤﺟﺮﺘﻟا ﺔﻣﺪﺧ ﻰﻠﻋ لﻮﺼﺤﻠﻟ
Chinese 若需免費的中文版本,請撥打 ID 卡上的電話號碼
French Pour demander une traduction gratuite en français, composez le numéro indiqué sur votre carte d’identité.
German Um eine kostenlose deutsche Übersetzung zu erhalten, rufen Sie bitte die Telefonnummer auf Ihrer
Ausweiskarte an.
Greek Για δωρεάν μετάφραση στα Ελληνικά, καλέστε τον αριθμό που αναγράφεται στην αναγνωριστική κάρτας
σας.
Haitian Creole Pou jwenn tradiksyon gratis nan lang Kreyòl Ayisyen, rele nimewo ki sou kat ID ou.
Italian Per la traduzione in italiano senza costi aggiuntivi, è possibile chiamare il numero indicato sulla tessera
identificativa.
Japanese
本語の無料翻訳については ID カードに書いてある番号に電話してください。
Khmer (Cambodian)
   
Korean 한국어로 무료 통역을 원하시면, ID 카드에 있는 번호로 연락하십시.
Laotian
າລ
ບການແປພາສາເປ
ນພາສາລາວທ
ໄດ
ເສຍຄ
າໃຊ
າຍ, ໃຫ
ໂທຫາເ
ເທ
ງບ
ດປະຈ
າຕ
ວຂອງທ
ານ.
Navajo
ﺎﮕﯾار ﮫﻣﺟرﺗ یارﯽﺳرﺎﻓ.دﯾﻧزﺑ ﮓﻧز نﺎﺗ ﯽﺋﺎﺳﺎﻧﺷ ترﺎﮐ رد جردﻧﻣ نﻔﻠﺗ هرﺎﻣﺷ ﮫﺑPersian
Polish Aby uzyskać bezpłatne tłumaczenie w języku polskim, należy zadzwonić na numer znajdujący się na Pana/i
dowodzie tożsamości.
Portuguese Para tradução grátis para português, ligue para o número no seu cartão de identificação.
Russian Для получения услуг бесплатного перевода на русский язык позвоните по номеру, указанному на
идентификационной карточке.
Spanish Por servicio de traducción gratuito en español, llame al número de su tarjeta de miembro.
Tagalog Para sa walang bayad na pagsasalin sa Tagalog, tawagan ang numero na nasa inyong ID card.
Vietnamese Để có bn dch tiếng Vit không phi tr phí, gi theo s trên th căn cưc ca bn.
DISCRIMINATION IS AGAINST THE LAW
Tufts Health Plan complies with applicable Federal civil
rights laws and does not discriminate on the basis of
race, color, national origin, age, disability, or sex. Tufts
Health Plan does not exclude people or treat them
dierently because of race, color, national origin, age,
disability, or sex.
Tufts Health Plan:
} Provides free aids and services to people with
disabilities to communicate eectively with us, such as:
— Written information in other formats (large print,
audio, accessible electronic formats, other formats)
} Provides free language services to people whose
primary language is not English, such as:
— Qualified interpreters
— Information written in other languages
If you need these services, contact Tufts Health Plan at
800.462.0224.
If you believe that Tufts Health Plan has failed to provide
these services or discriminated in another way on the
basis of race, color, national origin, age, disability, or sex,
you can file a grievance with:
Tufts Health Plan, Attention:
Civil Rights Coordinator Legal Dept.
705 Mount Auburn St. Watertown, MA 02472
Phone: 888.880.8699 ext. 48000, [TTY number —
800.439.2370 or 711]
Fax: 617.972.9048
Email: OCRCoordinator@tufts-health.com
You can file a grievance in person or by mail, fax, or
email. If you need help filing a grievance, the Tufts Health
Plan Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Oce for
Civil Rights, electronically through the Oce for Civil
Rights Complaint Portal, available at https://ocrportal.
hhs.gov/ocr/portal/lobby.jsf,
or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201
800.368.1019, 800.537.7697 (TDD)
Complaint forms are available at http://www.hhs.gov/
ocr/oce/file/index.html.
705 Mt Auburn Street - Watertown, MA 02472
tuftshealthplan.com - 800.462.0224