OMB OMB No. No. 0938-1378 0938-1378 Expires:7/31/2023 Expires:7/31/2023
INDIVIDUAL INDIVIDUAL ENROLLMENT ENROLLMENT REQUEST REQUEST FORM FORM TO TO ENROLL ENROLL IN IN A A MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE PRESCRIPTION PRESCRIPTION DRUG DRUG PLAN PLAN (PART (PART D) D) Who Who can can use use this this form? form?
People People with with Medicare Medicare who who want want to to join join aa Medicare Medicare Advantage Plan or Medicare Prescription Advantage Plan or Medicare Prescription Drug Drug Plan Plan To To join join aa plan, plan, you you must: must: •• Be a United States Be a United States citizen citizen or or be be lawfully lawfully present in the U.S. present in the U.S. •• Live Live in in the the plan’s plan’s service service area area Important: Important: To To join join aa Medicare Medicare Advantage Advantage Plan, Plan, you must also have both: you must also have both: •• Medicare Medicare Part Part A A (Hospital (Hospital Insurance) Insurance) •• Medicare Part B (Medical Medicare Part B (Medical Insurance) Insurance)
When When do do II use use this this form? form?
You You can can join join aa plan: plan: •• Between October Between October 15–December 15–December 77 each each year year (for coverage starting January 1) (for coverage starting January 1) •• Within Within 33 months months of of first first getting getting Medicare Medicare •• In certain situations where you’re In certain situations where you’re allowed allowed to to join join or or switch switch plans plans Visit Visit Medicare.gov Medicare.gov to to learn learn more more about about when when you you can sign up for a plan. can sign up for a plan.
What What do do II need need to to complete complete this this form? form?
Your Your Medicare Medicare Number Number (the (the number number on on your your red, white, and blue Medicare card) red, white, and blue Medicare card) •• Your Your permanent permanent address address and and phone phone number number Note: Note: You You must must complete complete all all items items in in Section Section 1. 1. The items in Section 2 are optional — The items in Section 2 are optional — you you can’t can’t be be denied denied coverage coverage because because you you don’t don’t fill fill them them out. out. ••
Reminders: Reminders: •• ••
If If you you want want to to join join aa plan plan during during fall fall open open enrollment (October 15–December 7), enrollment (October 15–December 7), the the plan plan must get your completed form by December must get your completed form by December 7. 7. Your plan will send you a bill for the plan’s Your plan will send you a bill for the plan’s premium. premium. You You can can choose choose to to sign sign up up to to have have your premium payments deducted from your premium payments deducted from your your bank bank account account or or your your monthly monthly Social Social Security Security (or (or Railroad Railroad Retirement Retirement Board) Board) benefit. benefit.
What What happens happens next? next?
Send Send your your completed completed and and signed signed form form to: to: Elderplan Inc. Elderplan Inc. Attention: Attention: Member Member Operations Operations th th Avenue 6323 7 6323 7 Avenue Brooklyn, Brooklyn, NY NY 11220 11220 Once Once they they process process your your request request to to join, join, they’ll contact you. they’ll contact you.
How How do do II get get help help with with this this form? form? Call Call Elderplan Elderplan Member Member Services Services at at 1-800-353-3765. TTY users can call 1-800-353-3765. TTY users can call 711. 711.
Or, Or, call call Medicare Medicare at at 1-800-MEDICARE 1-800-MEDICARE (1-800-633-4227). (1-800-633-4227). TTY TTY users users can can call call 1-877-486-2048 1-877-486-2048 En En español: español: Llame Llame aa Elderplan Elderplan al al 1-800-353-3765/ TTY 1-800-353-3765/ TTY 711 711 oo aa Medicare Medicare gratis gratis al al 1-800-633-4227 1-800-633-4227 yy oprima oprima el el 22 para para asistencia en español y un representante asistencia en español y un representante estará estará disponible disponible para para asistirle. asistirle.
According According to to the the Paperwork Paperwork Reduction Reduction Act Act of of 1995, 1995, no no persons persons are are required required to to respond respond to to aa collection collection of of information information unless unless it it displays displays aa valid valid OMB OMB control control number. number. The The valid valid OMB OMB control control number number for for this this information information collection collection is is 0938-NEW. 0938-NEW. The The time time required required to to complete complete this this information information is is estimated estimated to to average average 20 20 minutes minutes per per response, response, including including the the time time to to review review instructions, instructions, search existing data resources, gather the data needed, and complete and review the information collection. search existing data resources, gather the data needed, and complete and review the information collection. If If you you have have any any comments comments concerning concerning the the accuracy accuracy of of the the time time estimate(s) estimate(s) or or suggestions suggestions for for improving improving this this form, form, please please write write to: to: CMS, CMS, 7500 7500 Security Security Boulevard, Boulevard, Attn: Attn: PRA PRA Reports Reports Clearance Clearance Officer, Officer, Mail Mail Stop Stop C4-26-05, C4-26-05, Baltimore, Baltimore, Maryland Maryland 21244-1850. 21244-1850. IMPORTANT IMPORTANT Do Do not not send send this this form form or or any any items items with with your your personal personal information information (such (such as as claims, claims, payments, payments, medical medical records, records, etc.) etc.) to to the the PRA PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in in OMB OMB 0938-1378) 0938-1378) will will be be destroyed. destroyed. It It will will not not be be kept, kept, reviewed, reviewed, or or forwarded forwarded to to the the plan. plan. See See “What “What happens happens next?” next?” on on this this page page to to send send your your completed completed form form to to the the plan. plan.
H3347_EP16942_2021_Medicare_Enrollment_Form_C H3347_EP16942_2021_Medicare_Enrollment_Form_C
White Copy: To Office
55 Yellow Copy: To Member
