Florida Health Care Plans

MA-Only

5/17/2012 3:45:12 AM

Medicare Advantage (MA-Only) Medicare Enrollment Form

BY COMPLETING THIS ONLINE ENROLLMENT APPLICATION YOU ARE SENDING AN ACTUAL ELECTION TO FLORIDA HEALTH CARE PLANS.

When finished, click the Continue button at the bottom of the page.

The information you are providing is entirely confidential and will only be used for the purpose of completing your enrollment in Florida Health Care Plans.

A red asterisk (*) indicates the items in the box are required.

Please contact Florida Health Care Plan, Inc. if you need information in another language or format.

Enrollment period selection: *

Typically, you may enroll in a Medicare Advantage plan during the annual enrollment period between October 15 and December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of these periods.

Are you enrolling in a Medicare Advantage (MA-Only) plan during one of the following periods.

Annual Enrollment Period(Period between October 15th and December 7th of each year)?
Outside of the enrollment periods noted above?

Please check the Medicare Advantage (MA-Only) plan you want to enroll in: * Medvantage Plan - $0.00 per month.
Medvantage Plan with Optional Point of Service- $42.00 per month.

Summary of Benefits

Have you received and reviewed FHCP's 2011 Summary of Benefits for the plan you are enrolling in?

YesNo

Personal Information: *

Title:	Mr.Mrs.Ms.Dr.Rev.		Suffix:
First Name:		Middle Initial:	Last Name:
Date of Birth:			Gender:	MaleFemale
Home Phone:			Other Phone Number:
E-mail Address:

Permanent Residence: *

A permanent residence is normally the primary residence of an individual. FHCP may request documentation to prove residency in the FHCP service area. This documentation may include a voter’s registration card, driver’s license, tax bills, utility bills or other records. In the case of homeless individuals, an address of a shelter or clinic, or the address where the individual receives mail (e.g., social security checks) may be considered the place of permanent residence.

Permanent Residence Street Address (PO Box is not allowed):
City:		County:		State:		ZIP Code:

Check here if there is a different mailing address

Emergency Contact:

First Name:		Last Name:
Home Phone:		Relationship to You:

Please Provide Your Medicare Insurance Information: *

Please take out your Medicare Card to complete this section. - Please fill in these blanks so they match your red, white and blue Medicare card. You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Name as it appears on your Medicare card:

First Name:	Last Name:		MI:
Medicare Claim Number:	Gender:	MaleFemale
HOSPITAL (Part A) Effective Date:
MEDICAL (Part B) Effective Date:

Paying Your Plan Premium: *

If you have elected the Optional Point of Service benefit, you can pay by mail, Direct Debit (ACH Debit), or Pre-Authorized Credit Card each month. You can also choose to pay your premium by automatic deduction from your Social Security Benefit Check each month.

If you do not select a payment option, you will get a coupon book.

Please select a premiun payment option: Get a coupon book
Direct Debit (ACH Debit) each month (FHCP will be sending you an authorization form. Please complete and return at your earliest convenience.)
Credit Card (FHCP will be sending you an authorization form. Please complete and return at your earliest convenience.)
Automatic deduction from your monthly SSA benefit check (The Social Security deduction may take two or more months to take effect. In most cases the first deduction from your Social Security benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. You are however responsible for any premiums not withheld.)

Please read and answer these important questions: *


1.	Have you recently moved into FHCP's service area?
	YesNo


2.	Do you have End Stage Renal Disease(ESRD)?
	YesNo


3.	Some 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 Florida Health Care Plan, Inc?
	YesNo


4.	Are you a resident in a long-term facility, such as a nursing home?
	YesNo


5.	Are you enrolled in your State Medicaid program?
	YesNo


6.	Do you or your spouse work?
	YesNo

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format:
Spanish
Braille
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Please contact Florida Health Care Plans at 1-877-615-4022 if you need information in another format or language than what is listed above. Our office hours are Monday through Friday From 8am to 5pm. TTY users should call TRS Relay 711

E-mail the webmaster at webmaster@fhcp.com with other questions or comments about this site.

H1035_A5006 CMS Approved 11/01/2010