Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form (Page 3 of 5) in pdf

Please read and answer these important questions:

q YES q NO

1. Do you have End-Stage Renal Disease (ESRD)?

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor

showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.

2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health

benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to Harvard Pilgrim Health Care?

q YES q NO

If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage:

ID # for this coverage:

Group # for this coverage:

3. Are you a resident in a long-term care facility, such as a nursing home?

q YES q NO

If “yes”, please provide the following information:

Name of Institution:

Phone Number:

Address:

(Number and Street)

4. Are you enrolled in your State Medicaid program?

q YES q NO

If yes, please provide your Medicaid number:

5. Do you or your spouse work?

q YES q NO

Please choose the NAME of a Primary Care Physician (PCP), Clinic or Health Center:

PCP ID Number:

FIRST Name:

MI:

LAST Name:

(use boxes below)

Are you an existing member of this PCP?

q Yes q No

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another

format: q

Large Print

Please contact Harvard Pilgrim Health Care at 888-609-0692 if you need information in another format or language than what is listed above. Our

office hours are October 1st to February 14th from 8 a.m. to 8 p.m. 7 days a week, February 15th to September 30th from 8 a.m. to 8 p.m. Monday

through Friday. TTY users should call 711.

Please Read This Important Information for MA-PD Plans

If you currently have health coverage from an employer or union, joining Harvard Pilgrim Health Care could affect your employer

or union health benefits. You could lose your employer or union health coverage if you join Harvard Pilgrim Health Care. Read the

communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications.

If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Please Read and Sign

By completing this enrollment application, I agree to the following:

Harvard Pilgrim Health Care is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A

and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in

another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the

future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an

enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.

Harvard Pilgrim Health Care serves a specific service area. If I move out of the area that Harvard Pilgrim Health Care serves, I need to notify the plan so

I can disenroll and find a new plan in my new area. Once I am a member of Harvard Pilgrim Health Care, I have the right to appeal plan decisions about

payment or services if I disagree. I will read the Evidence of Coverage document from Harvard Pilgrim Health Care when I get it to know which rules I must

follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the

country except for limited coverage near the U.S. border.

(Continued on next page)

White Copy: Office, Yellow: Member

Y0098_16120 Accepted

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