Medicare Advantage Enrollment/election Form For Health Net/seniority Plus (Page 4 of 4) in pdf

I understand that beginning on the date the Medicare Advantage Plan coverage begins, I must get all of my health

care from this Medicare Advantage Plan, except for emergency or urgently needed services or out-of-area dialysis

I understand that beginning on the date the Medicare Advantage Plan coverage begins, I must get all of my health

services. Services authorized by this Medicare Advantage Plan and other services contained in my Evidence of

care from this Medicare Advantage Plan, except for emergency or urgently needed services or out-of-area dialysis

Coverage document (also known as a member contract or subscriber agreement) will be covered. Without

services. Services authorized by this Medicare Advantage Plan and other services contained in my Evidence of

authorization, NEITHER MEDICARE NOR THIS MEDICARE ADVANTAGE PLAN WILL PAY FOR THE SERVICES.

Coverage document (also known as a member contract or subscriber agreement) will be covered. Without

authorization, NEITHER MEDICARE NOR THIS MEDICARE ADVANTAGE PLAN WILL PAY FOR THE SERVICES.

RELEASE OF INFORMATION:

By joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to

RELEASE OF INFORMATION:

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

By joining this Medicare Health Plan, I acknowledge that the Medicare Health Plan will release my information to

that this Medicare Health Plan will release my information, including any prescription drug event data, to Medicare,

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

who may release it for research and other purposes which follow all applicable Federal statutes and regulations.

that this Medicare Health Plan will release my information, including any prescription drug event data, to Medicare,

The information on this enrollment/election form is correct to the best of my knowledge. I understand that if I

who may release it for research and other purposes which follow all applicable Federal statutes and regulations.

intentionally provide false information on this form, I will be disenrolled from the plan.

The information on this enrollment/election 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 I live) on this application means that I have read and understand the contents of this application. If signed by

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the

State I live) on this application means that I have read and understand the contents of this application. If signed by

law to complete this enrollment and 2) documentation of this authority is available upon request from Medicare.

All benefits offered under this Medicare health plan, including optional supplemental benefits, are subject to the

ARBITRATION AGREEMENT: I understand that (except for Small Claims Court cases, claims subject to a

Medicare appeals procedures and are not subject to arbitration. Conversely, all other claims including, but not

Medicare appeals procedure, and, if I am enrolled in coverage that is subject to the ERISA claims procedure

ARBITRATION AGREEMENT: I understand that (except for Small Claims Court cases, claims subject to a

limited to, the following claims, regardless of how they are characterized, are subject to arbitration: Determinations

regulation (29 CFR 2560.503-1), certain beneﬁt-related disputes), any dispute between myself, my heirs,

Medicare appeals procedure, and, if I am enrolled in coverage that is subject to the ERISA claims procedure

on items or services purchased by my employer, over and above the Medicare approved benefit package, such

relatives, or other associated parties on the one hand and Health Plan, its health care providers, or other

regulation (29 CFR 2560.503-1), certain beneﬁt-related disputes), any dispute between myself, my heirs,

as payments of premiums or beneficiary cost sharing provided by my employer, any disputes between myself, my

associated parties on the other hand, for alleged violation of any duty arising out of or related to membership

relatives, or other associated parties on the one hand and Health Plan, its health care providers, or other

heirs, relatives, or other associated parties on the one hand and the health plan, any contracted health care benefit

in Health Plan, including any claim for medical or hospital malpractice (a claim that medical services were

associated parties on the other hand, for alleged violation of any duty arising out of or related to membership

providers, administrators, or other associated parties on the other hand for alleged violation of any duty arising out

unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises

in Health Plan, including any claim for medical or hospital malpractice (a claim that medical services were

of or related to membership in the health plan that is not subject to the Medicare appeals process, including any

liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be

unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), for premises

claim for medical or hospital malpractice (a claim that medical services were unauthorized or were improperly,

decided by binding arbitration under California law and not by lawsuit or resort to court process, except as

liability, or relating to the coverage for, or delivery of, services or items, irrespective of legal theory, must be

negligently, or incompetently rendered), for premises liability, or relating to the delivery of, services or items,

applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury

irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or

decided by binding arbitration under California law and not by lawsuit or resort to court process, except as

trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in

resort to court process. By signing below, I agree to give up our right to a jury trial and accept the use of binding

applicable law provides for judicial review of arbitration proceedings. I agree to give up our right to a jury

arbitration for claims that are not subject to the Medicare appeals procedures. I understand that the full arbitration

the Evidence of Coverage.

trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in

provision is in the health plan’s coverage document, which is available for my review.

the Evidence of Coverage.

Signature:

Date

Signature:

Date

If you are the authorized representative,

you must sign above and provide the following information:

Date

If you are the authorized representative,

you must sign above and provide the following information:

Date

Name:

(please print)

Name:

Address:

(please print)

Address:

Phone Number: (

)

Phone Number: (

)

Relationship to Enrollee:

SKU 60273108 (8/2016)

DISTRIBUTION: Top Copy: Health Net; Second Copy: UC; Third Copy: Member

page 3

SKU 60097112 (11/2012)

DISTRIBUTION: White (Health Plan Copy); Canary (Employer Group Copy);

SKU 60097112 (11/2012)

DISTRIBUTION: White (Health Plan Copy); Canary (Employer Group Copy);

Medicare Advantage Enrollment/election Form For Health Net/seniority Plus Page 4

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