Medicare Advantage Enrollment/election Form For Health Net/seniority Plus printable pdf download

MEDICARE ADVANTAGE ENROLLMENT/ELECTION

Mail second copy to: RASC

P.O. Box 24570

FORM FOR HEALTH NET/SENIORITY PLUS

Oakland, CA 94623-1570

UBEN 125 (R8/16) University of California Human Resources

OR fax to:

510-465-9037

This Enrollment/Election Form has been sent to you because you or an eligible family member has enrolled in Health

Net/Seniority Plus, a Medicare Advantage plan which requires you to assign your Medicare to your plan. Please print

clearly using a blue or black ballpoint pen. Each person on Medicare must complete a separate form.

• “Subscriber” means the University of California retiree who is carrying the medical insurance through UC.

• “Requested Effective Date” is the first of the month after your plan receives the signed and completed form and no

earlier than the month the person becomes eligible for and enrolls in Medicare Parts A and B. (Forms submitted 90 days

or more before the Medicare Part B Effective Date will be denied.)

Read the entire agreement before you sign the form.

Top copy—send to plan:

Health Net/Seniority Plus

Attn: Enrollment Services

P.O. Box 10420

Van Nuys, CA 91499-6208

Second copy—send or fax to UC at address/fax above.

Third copy—keep for your records.

For help with this form, call the UC Retirement Administration Service Center (1-800-888-8267) or your location’s Health

Care Facilitator; for the contact list, visit: ucnet.universityofcalifornia.edu/contacts/health-care-facilitators.html

FORM QUESTION

WHAT TO ENTER

Requested Effective Date

If you leave the date blank, your plan will assign the first of the

month you are eligible for and enrolled in Medicare, and that they

are in receipt of this completed form.

Desired Contracting Medical Group

Enter your medical group (e.g., Hill Physicians, UCSD

Healthcare). Check your plan’s website or call to ensure your

group and specialists are contracted with Medicare and your plan.

This is very important.

Desired Contracting Physician

Enter your primary care physician. Check with your doctor to

make sure he/she is contract ed with Medicare for your plan.

This is very important.

Medical Group/Physician No.

Input if known. If not, leave blank.

Last Name, First Name, MI

Name of the person enrolling. If spouse, enter spouse’s name.

Permanent Residence Address, City, State, Zip

Address of enrollee. No P.O. Boxes accepted—need street address.

Social Security Number (SSN) and Date of Birth

Enter SSN and birthdate for enrollee.

Are you the Subscriber?

Answer Yes, if the enrollee is the UC retiree/survivor. No, if not.

Enter the UC retiree’s full name and SSN. This is very important.

Subscriber’s Name and SSN

Enter all numbers, letters and dates from enrollee’s red/white/

Medicare Card

blue Medicare card OR send a copy of the card to UC.

Question 2 Are you covering a spouse or dependent? Answer Yes if enrollee is the UC retiree/survivor and is covering

family members.

Question 3 Do you or your spouse work?

Answer Yes if enrollee or UC retiree is employed and eligible for

any health insurance benefits elsewhere as an employee.

Question 5 Have other drug coverage?

Answer Yes if enrollee has another non-UC prescription drug

plan, separate from UC insurance. No, if none.

Signature and Date

Enrollee must sign and date here. This is very important.

Authorized Representative’s Signature plus Name,

If the enrollee did not sign, the person legally responsible to sign

for him/her should sign and date here. This is very important.

Address, Phone, Relationship to enrollee

Your medical plan and UC must both receive this form before your Medicare Advantage coverage and any Part B

reimbursements can begin.

Medicare Advantage Enrollment/election Form For Health Net/seniority Plus

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