Florida Health Care Plan, Inc. An Affiliate of Halifax Health MA-Only

9/5/2008 8:48:55 PM

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.

Enrollment period selection:*

Are you enrolling in a Medicare Advantage (MA-Only) plan during one of the following periods.
  Annual Enrollment Period(Period between November 15th and December 31st of each year)?
Open Enrollment Period (Period between January 1st and March 31st 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 -$17.00 per month.
Medvantage Plan with Optional Point of Service - $47.00 per month.   Summary of Benefits

Have you received and reviewed FHCP's 2008 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, a Post Office box, 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:
City:		State:		ZIP Code:

Check here if there is a different mailing address

Emergency Contact:

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

Have you ever been a member of FHCP?	YesNo

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:*

        You can have the monthly premium for this Medicare Advantage plan automatically deducted from your Social Security check. If you don't choose this option, we will send you a bill each month which you can pay by mail; or Direct Debit (ACH Debit); or Pre-Authorized Credit Card option. Generally you must stay with the option you choose for the rest of the year.

 
Please select a premiun payment option: Receive a coupon book
Electronic funds transfer(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

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 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

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

© 2007 Florida Health Care Plans, Inc. All rights reserved.

H1035 FHCP A 2938 10/2007