Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form (Page 2 of 5) in pdf

Please contact Harvard Pilgrim Health Care if you need information in another language or format (Braille).

To Enroll in Harvard Pilgrim Health Care, Please Provide the Following Information:

Please check which plan you want to enroll in:

q Stride Value RX (HMO) Massachusetts : $48

q Stride Value RX Plus (HMO) Massachusetts: $138

q Stride Value RX (HMO) Maine: $0

q Stride Value RX Plus (HMO) Maine: $64

q Stride Value RX (HMO) New Hampshire: $20

q Stride Value RX Plus (HMO) New Hampshire: $73

LAST Name:

q Mr. q Mrs. q Ms.

FIRST Name:

MI:

(use boxes below)

M M

D D

Y Y

Home Phone Number:

Birth Date:

Sex: q M q F

Alternate Phone Number: (optional)

Permanent Residence Street Address 1:

(PO Box is not allowed)

Street Number

Street Name

Lot /Apartment

City:

State:

Zip Code:

Mailing Address (only if different from your Permanent Residence Address):

Street Number

Street Name

Lot /Apartment

City:

State:

Zip Code:

Emergency contact:

(optional)

FIRST Name:

MI:

LAST Name:

Phone Number:

Relationship to You:

E-mail Address:

(optional)

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

SAMPLE ONLY

Name:

red, white and blue Medicare card

- OR -

Medicare Claim Number:

• Attach a copy of your Medicare card or your

Sex: q M q F

letter from Social Security or the

Effective Date:

Railroad Retirement Board.

Is Entitled To

M M

D D

Y Y

HOSPITAL

(Part A)

You must have Medicare Part A and Part B to join a Medicare

MEDICAL

(Part B)

Advantage plan.

Paying Your Plan Premium

Please select a premium payment option:

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how

you would prefer to pay it. You can pay by mail or Electronic Funds Transfer (EFT) each month. You can also choose to pay your

Get a bill.

premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are

Electronic funds transfer (EFT) from your bank account each

assessed a Part D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be

month. Please enclose a VOIDED check or provide the following:

responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social

Account holder name:_____________________________

Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay Harvard Pilgrim Health Care the Part D-IRMAA. You

can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail or Electronic

Bank routing number:_____________________________

Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or

Bank account number:_____________________________

Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment

Account type:

Checking

Saving

Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to

Automatic deduction from your monthly Social Security or

your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare

Railroad Retirement Board (RRB) benefit check. (The Social

or RRB. DO NOT pay Harvard Pilgrim Health Care the Part D-IRMAA. People with limited incomes may qualify for extra help to pay

Security/RRB deduction may take two or more months to begin

for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription

after Social Security or RRB approves the deduction. In most

drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or

cases, if Social Security or RRB accepts your request for automatic

a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra

deduction, the first deduction from your Social Security or RRB

help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

benefit check will include all premiums due from your enrollment

You can also apply for extra help online at If you qualify for extra help with your Medicare

effective date up to the point withholding begins. If Social Security

prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium,

or RRB does not approve your request for automatic deduction, we

we will bill you for the amount that Medicare doesn’t cover. If you don’t select a payment option, you will get a bill each month.

will send you a paper bill for your monthly premiums).

White Copy: Office, Yellow: Member

Y0098_16120 Accepted

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Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form Page 2

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