Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form (Page 4 of 5) in pdf

Please Read and Sign Below

I understand that beginning on the date Harvard Pilgrim Health Care coverage begins, I must get all of my health care from Harvard

Pilgrim Health Care, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Harvard

Pilgrim Health Care and other services contained in my Harvard Pilgrim Health Care Evidence of Coverage document (also known as a

member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR HARVARD PILGRIM

HEALTH CARE WILL PAY FOR THE SERVICES.

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

Health Care, he/she may be paid based on my enrollment in Harvard Pilgrim Health Care.

Release of Information: By joining this Medicare health plan, I acknowledge that Harvard Pilgrim Health Care will release my information

to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Harvard

Pilgrim Health Care 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 the laws of the State 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 from Medicare.

M M

D D

Y Y

Signature:

Today’s Date:

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

Name:

Phone Number:

Address:

Relationship to Enrollee:

OFFICE USE ONLY:

Name of staff member/agent/broker (if assisted in enrollment): _____________________________________________________

Agent Received Date

Signature: ___________________________

Effective Date:

(M M /D D/ Y Y Y Y )

Election Type: q ICEP/IEP q AEP q SEP(type)

q Not Eligible

COUNTY:

Plan ID#

Agency of Agent:________________________________ Current Insurance:__________________________________________

Agent Name:

(First)

(Last)

Agent ID#:

Date Received:

Member ID #

White Copy: Office, Yellow: Member

Y0098_16120 Accepted

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Harvard Pilgrim Health Care Mapd Individual Enrollment Request Form Page 4

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