Pre-Enrollment Qualification Assessment Form (Page 2 of 2) in pdf

Pre-Enrollment Qualification Assessment Form Page 2

Health care provider(s) who can verify your chronic condition(s)

Provider #1

Provider #2

Provider name:

Provider address:

Provider phone: (

)

Provider phone: (

)

Provider fax: (

)

Provider fax: (

)

Authorization for Disclosure of Health Information to Verify Chronic Condition(s):

I hereby authorize the disclosure of my health information by the providers listed above to Health Net in order

to verify that I have been diagnosed with a chronic condition which qualifies me for enrollment in Health Net’s

chronic special needs plan. This authorization applies to all health information maintained by the provider

concerning my medical history for the chronic condition(s) indicated above.

Note: Information disclosed as a result of this authorization will be protected by Health Net in accordance with

applicable state and federal laws and requirements.

Signature

Enrollee signature:

Date:

Broker/Agent name (if applicable):

Broker/Agent signature (if applicable):

Date:

For more information or for assistance with this form, please call Health Net Member Services at one of the

following toll-free numbers:

Arizona: 1-800-977-7522 (TTY: 711)

California: 1-800-431-9007 (TTY: 711)

Oregon: 1-888-445-8913 (TTY: 711)

Hours of operation: From October 1 through February 14, our office hours are 8:00 a.m. to 8:00 p.m.,

7 days a week, excluding certain holidays. However, after February 14, your call will be

handled by our automated phone system on weekends and certain holidays.

Health Net has a contract with Medicare to offer HMO SNP plans. Enrollment in a Health Net Medicare

Advantage plan depends on the renewal of these contracts.

6030704 CA111292 (7/14) 2 of 2

Material ID # Y0035_2015_0030 (H0351, H0562, H6815) CMS Accepted 08142014

Pre-Enrollment Qualification Assessment Form Page 2