Member Enrollment Form - Tufts Health Plan Page 2
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1
2WELCOME TO TUFTS HEALTH PLAN
New Members — Register at for fast access to your secure online account and personal benefit information.
When the Application is Complete
Please fill in the “employee” sections of this membership
Product Codes
application completely. Failure to do so could delay
•
Give the application to your employer.
Write the corresponding letter in the product box in
enrollment. You will receive your Tufts Health Plan ID
•
Employee keeps the yellow copy. This is also your
the member section of the enrollment application.
card and member benefit document soon. If you need
temporary ID.
a temporary ID, please use the yellow copy of this
•
Employer keeps the pink copy.
A - HMO Premium
Q - Carelink
completed form.
•
Employer mails the original white copy to:
B - HMO Value
R - HMO Select 15
Tufts Health Plan
Employer Section
C - HMO Basic
S - HMO Select 20
P.O. Box 9186
Your employer must fill out this section.
Watertown, MA 02471-9186
D - HMO Choice Copay
T - Advantage HMO
Select 750
E - Advantage HMO
Employee Section
If You Need Emergency Care
U - Advantage HMO
G - Advantage HMO
•
Personal Information: Complete all enrollment
If a health care emergency occurs, go to the nearest
Select 2000
Saver
information. If your plan (HMO, POS, or EPO) requires the
medical facility or call 911. An emergency is a serious
W - Rhode Island
H - POS
selection of a primary care provider (PCP), be sure to fill
injury or the onset of a serious condition that prevents
Healthpact
out this section for all members, including dependents.
you from taking the time to call your PCP.
I - POS Choice Copay
X - Your Choice HMO
•
Product Code: Please be sure to fill in the correct
J - EPO
Notices
product code for the plan you have selected.
Y - Your Choice PPO
K - EPO Choice Copay
•
Primary Care Provider: If your plan requires you to
By enrolling, you understand and agree that if you or any
Z - Steward Community
L - PPO
choose a PCP, it is important that you select one right
of your enrolled dependents obtain a health care benefit
Choice
away. Until we know who your PCP is, your in-network
or payment that you are not entitled to receive, or if you
M - Advantage PPO
RIC - Rhode Island
benefits may be limited to emergency services only.
knowingly present a claim that contains a false statement,
O - Advantage PPO
Conversion
To find a PCP, visit and use the
you can be liable for the full amount of the health care
Saver
Doctor Search feature. On this application, indicate
benefit or payment made and for reasonable attorney’s
P - Navigator by Tufts
whether you are an established patient of the PCP you
fees and costs, including the cost of the investigation.
Health Plan
have listed. (You are an established patient if you have
routinely received health care services from this provider
Tufts Health Plan arranges for the provision of health
in the past.) If you are selecting a new PCP, contact the
care services through agreements with independent
Need Help?
We speak 140 languages.
provider’s office right away and introduce yourself as a
community-based health care professionals working in
If you need assistance select-
Call Member Services.
new Tufts Health Plan member. Ask if they are taking
private offices and with hospitals throughout the Tufts
ing a PCP, visit tuftshealth-
new patients and if the provider would like to schedule
Health Plan service area. These providers are independent
and use the Doctor
a physical exam. You will then need to transfer your
contractors and not employees, agents, or representatives
Search feature. If you need
medical records to your new PCP.
of Tufts Health Plan. Tufts Health Plan does not directly
help filling out this form, call
•
Other Health Coverage: If you have other or additional
provide health care services.
a Member Services Specialist.
insurance (such as Medicare), please check the correct
box and fill in the requested information. If you do not
Member Services:
have any other insurance, be sure to check the “No” box.
800-462-0224
18079-12/11
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