Medicare Prescription Drug Plan Individual Enrollment Form (Page 4 of 4) in pdf

EnvisionRx Plus Clear Choice serves a specific service area. If I move out of the area that EnvisionRx Plus

Clear Choice serves, I need to notify the plan so I can disenroll and find a new plan in my new area. I understand

that I must use network pharmacies except in an emergency when I cannot reasonably use EnvisionRx Plus Clear

Choice network pharmacies. Once I am a member of EnvisionRx Plus Clear Choice, I have the right to appeal

plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from

EnvisionRx Plus Clear Choice when I get it to know which rules I must follow to get coverage.

I understand that if I leave this plan and don’t have or get other Medicare prescription drug coverage or creditable

prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my

premium for Medicare prescription drug coverage in the future.

I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or

contracted with EnvisionRx Plus Clear Choice, he/she may be paid based on my enrollment in EnvisionRx Plus

Clear Choice.

Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or

other Medicare Advantage or Prescription Drug Plan options, medical assistance through the state Medicaid

program, and the Medicare Savings Program.

Release of Information:

By joining this Medicare prescription drug plan, I acknowledge that EnvisionRx Plus Clear Choice will release

my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I

also acknowledge that EnvisionRx Plus Clear Choice will release my information, including my prescription drug

event data, to Medicare, who may release it for research and other purposes, which follow all applicable Federal

statutes and regulations. 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.

I understand that my signature (or the signature of the person authorized to act on my behalf under State law where

I live) on this application means that I have read and understand the contents of this application. If signed by an

authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law

to complete this enrollment and 2) documentation of this authority is available upon request by Medicare.

Today’s Date:

Signature:

If you are the authorized representative, you must sign above and provide the following information:

Name: ___________________________________________________________________________________________

Address: __________________________________________________________________________________________

Phone Number: (_______) _________- _________________

Relationship to Enrollee _____________________________________________________________________________

BROKER REQUIRED FIELDS – FAX APPLICATIONS TO: 844-293-4756

Name of Agent/Broker:____________________________ Signature: ______________________________

Writing Number (Agent ID): ______________________ Date: ________________

Medicare Prescription Drug Plan Use Only:

Plan ID#:____________

Effective Date of Coverage: ________________ IEP: _______ AEP: _______ SEP(type)_______

Date Application Received by Plan:__________________Entered By: _____________Date Entered: __________

S7694_2015 E1 App_CC2 Approved 01212015

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Medicare Prescription Drug Plan Individual Enrollment Form Page 4