AmeriHealth Advantage Medicare Part D ... - AmeriHealth.com

MEDICARE PART D PRESCRIPTION DRUG
PLAN INDIVIDUAL ENROLLMENT FORM
INSTRUCTIONS: Please complete all sections of this form. Please read each statement in sections G and H.
Sign and date where indicated on this front page. Use the postage-paid business reply envelope or mail this
completed form to: PO Box 41514, Philadelphia, PA 19101-1514. For information, call 1-866-456-1695
(TTY users should call 1-866-456-1683).
A. Personal Information (please print clearly)
OFFICE USE ONLY
Group # _________________
EV Status _______________
Effective Date ____________
Disenroll Date ____________
Name ___________________________________
Address _________________________________
City, State & Zip ___________________________
Social Security No.
––
County
Home Phone
( )
C. Medicare Information (copy directly from your Medicare card)
E-mail Address ___________________________
Date of Birth
Gender
Male Female
B. Enroll me in the plan checked below:
AmeriHealth Advantage Option 1
PA/WV: $30.30/mo.
SAMPLE ONLY
Name: _________________________________
Medicare Claim Number
__ __ __ - __ __ - __ __ __ __ __
Is Entitled To
Effective Date
HOSPITAL (Part A) ____________
MEDICAL (Part B) ____________
D. Please select your premium payment option
You can have the monthly premium for this Medicare drug plan automatically deducted from your Social Security check, or automatically
withdrawn from your bank account by Electronic Funds Transfer (EFT). If you don’t choose one of these automated options, we will
send you a bill each month, which you can pay by mail. Generally, you must stay with the option you choose for the rest of the year.
Please indicate your payment option: Deduction from Social Security check Paper Bill
Electronic Funds Transfer (You must complete and send the enclosed Zipcheck form AND a voided check.)
If you select Deduction from Social Security check or Electronic Funds Transfer, you will not receive a bill each month.
Note: If you qualify for financial assistance with your Medicare Part D prescription drug coverage costs, Medicare may cover
all or a portion of your plan premium. Any difference owed by you will be collected by the method you’ve checked above.
E. Please answer the following questions to help Medicare coordinate your benefits
1. S ome individuals may have other drug coverage, including other private insurance, TRICARE, federal employee health
benefits coverage, VA benefits or State Pharmaceutical Assistance Programs.
Will you have other prescription drug coverage in addition to AmeriHealth Advantage? Yes No
If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:
Name of other coverage
ID No. for this coverage
Group number for this coverage
2. Are you a resident in a long-term care facility, such as a nursing home? Yes No
If “yes,” please provide the name of the institution
Street address and phone number of institution
F. Please Read and Sign Below
I understand that my signature* on this application means that I have read the back of this form and understand the
contents of this application. 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.
Applicant or Guardian Signature*
Date
Guardian Name (print)
Telephone No.
*Or that of a person authorized to act on my behalf under the laws of the state where I reside. If signed by another individual,
the signature certifies that the person is authorized under state law to complete this enrollment and that documentation of this
authority is available upon request by AmeriHealth Advantage or by Medicare.
Check here if anyone helped you fill out this application. He or she must sign below:
Signature Date Relationship to Applicant

G. STOP - Please Read This Important Information
If you are a member of a Medicare Advantage plan (like an HMO or PPO), you may already have a prescription drug benefit from your
Medicare Advantage plan that will meet your needs. By joining AmeriHealth Advantage, your membership in your Medicare Advantage plan
will end. This will affect both your doctor and hospital coverage as well as your prescription drug benefits. Read the information that your
Medicare Advantage plan sends you and if you have questions, contact your Medicare Advantage plan.
If you currently have health coverage from an employer or union, joining AmeriHealth Advantage could affect your employer or union
health benefits and may change how your current coverage works. Read the communications your employer or union sends you. If you
have questions, visit their Web site, or contact the office listed in their communications. If there is no information on whom to contact, your
benefits administrator or the office that answers questions about your coverage can help.
H. Enrollment Authorization
Please read carefully. Sign the front page after reading all statements in this section.
1. I understand AmeriHealth Advantage is a regional Medicare Part D Prescription Drug Plan with a Medicare contract.
2. I understand AmeriHealth Advantage is a Medicare Part D Prescription Drug Plan and is in addition to my coverage under Medicare
Part A (hospital) and Part B (medical). Therefore, I will need to keep my Medicare coverage. It is my responsibility to inform AmeriHealth
Advantage of any prescription drug coverage that I have or may get in the future. I can be in only one Medicare Part D Prescription Drug
Plan at a time. Enrollment in the plan is generally for the entire year.
3. I understand I may disenroll from AmeriHealth Advantage only at certain times of the year, or under special circumstances, by sending
a written request to AmeriHealth Advantage or by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
I can talk to a Medicare customer service representative 24 hours a day, seven days a week.
4. I understand AmeriHealth Advantage serves a specific service area. If I move out of the area that AmeriHealth Advantage serves, I need
to notify the plan so I can disenroll and find a new plan in my new area.
5. I understand that once I am a member of AmeriHealth Advantage, I have the right to appeal AmeriHealth Advantage decisions about
payment or service if I disagree. I will read the Evidence of Coverage document from AmeriHealth Advantage when I receive it to know
the rules I must follow in order to receive coverage with this Medicare drug plan. I understand that AmeriHealth Advantage will send me
final approval of my enrollment in the plan.
6. I understand that by joining this Medicare Part D Prescription Drug Plan, I acknowledge that AmeriHealth Advantage will release my
information to Medicare and other plans as is necessary for treatment, payment and health care operations.
7. I understand that if I obtain prescriptions outside the AmeriHealth Advantage network, I will be responsible for payment in full. I
understand that I can submit a prescription claim form to AmeriHealth Advantage for reimbursement minus the applicable copay or
coinsurance. I understand that prescription drugs obtained outside of the United States are not covered.
8. I understand that the person who is discussing plan options with me is either employed by or contracted with the QCC Insurance
Company offering AmeriHealth Advantage. The person may be compensated based on my enrollment in a plan.
9. Benefits, premiums and cost sharing may change January 1, 2008.
10. If I have special needs, this document may be available in other formats.
Underwritten by QCC Insurance Company.
C0004_HPC06_62a
ADVA-6351-APP(9/06)