Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form printable pdf download

Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form

Enrollment Form

Harvard Pilgrim Health Care

MAPD Individual Enrollment Request Form

ENROLLMENT INSTRUCTIONS

The following steps must be completed to become a member of Harvard Pilgrim Health Care - an HMO with a

Medicare contract. Enrollment in Stride Value RX (HMO) and Stride Value RX Plus (HMO) depends on contract renewal.

1. Please fill out the entire form legibly and accurately. Your Medicare information must be filled out exactly as it appears

on your Medicare card.

2. Be sure to read each item carefully so that you fully understand the information.

3. You must sign and date the enrollment form.

4. Keep the yellow copy to serve as your temporary proof of membership.

Member Services: 888-609-0692

TTY/TDD: 711

Dates

Days

Times

October 1, 2015 to February 14, 2016

7 days a week

8 a.m. to 8 p.m.

February 15, 2016 to September 30, 2016 Monday through Friday 8 a.m. to 8 p.m.

October 1, 2016 to December 31, 2016

7 days a week

8 a.m. to 8 p.m.

Please note that Harvard Pilgrim Health Care cannot consider this application “complete” until your eligibility for

Medicare Part A and enrollment in Medicare Part B has been confirmed.

HARVARD PILGRIM HEALTH CARE

PO Box 152108, Tampa, FL 33684-2108

Y0098_16120 Accepted

Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form