Medicareblue Rx Individual Change Form Page 5
Download a blank fillable Medicareblue Rx Individual Change Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medicareblue Rx Individual Change Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6F. ENROLLMENT AUTHORIZA TION: By completing this enrollment application, I agree to
the following:
After carefully reading all statements in this section, please sign Section E of this form.
Keep the copy marked “Enrollee” for your records.
1. I understand that MedicareBlue Rx (PDP) is a regional Medicare prescription drug plan and has a
contract with the Federal government. Coverage is available to residents of the service area and
separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue
Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue
Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of
South Dakota* and Blue Cross Blue Shield of Wyoming.*
*Independent licensees of the Blue Cross and Blue Shield Association
2. I understand that if I am getting assistance from a sales agent, broker or other individual employed by
or contracted with one of the independent Blue Cross and Blue Shield plans offering MedicareBlue Rx,
he/she may be paid based on my enrollment in MedicareBlue Rx.
3. Release of Information: By joining this Medicare prescription drug plan, I acknowledge that
MedicareBlue Rx will release my information to Medicare and other plans as necessary for treatment,
payment and health care operations, and as otherwise permitted by law. I also acknowledge that
MedicareBlue Rx will release my information, including my prescription drug event data, to Medicare,
who may release it for research and other purposes that follow all applicable Federal statutes
and regulations.
4. 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.
5. I understand that beginning on the date MedicareBlue Rx coverage begins, I must get all of my
prescription drug services from MedicareBlue Rx. Prescription drugs authorized by MedicareBlue Rx
and contained in my MedicareBlue Rx Evidence of Coverage document (also known as a member
contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR
MEDICAREBLUE RX WILL PAY FOR THE SERVICES.
Distribution:
White Copy: Carrier
Yellow Copy: Enrollee
4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical