How to fill out the enrollment form

Who can use this form?

People with Medicare who want to join a Medicare Advantage Plan

To join a plan, you must:

• Be a United States citizen or be lawfully present in the U.S.
•  Live in the plan’s service area

Important: To join a Medicare Advantage Plan, you must also have both:

• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)

When do I use this form?

You can join plan:

• Between October 15–December 7 each year (for coverage starting January 1)
• Within 3 months of first getting Medicare
• In certain situations where you’re allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

• Your Medicare Number (the number on your red, white, and blue Medicare card)
• Your permanent address and phone number

Note: You must complete all items in Section 1. The items in Section 2 are optional — you can’t be denied coverage because you don’t fill them out.

Reminders:

• If you want to join a plan during fall open enrollment (October 15–December 7), the plan must get your completed form by December 7.
• Your plan will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?

Once they process your request to join, they’ll contact you

How do I get help with this form?

Call PruittHealth Premier at 1-855-855-0668 (TTY 711) 1-855-855-0759 (TTY 711) 1-855-855-0759 (TTY 711).

Or, call Medicare at 1-800-MEDICARE (1-800-633- 4227). TTY users can call 1-877-486-2048.

En español: Llame a PruittHealth Premier al 1-855-855-0668 (TTY 711) 1-855-855-0759 (TTY 711) 1-855-855-0759 (TTY 711) o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.

Individuals experiencing homelessness

If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., social security checks) may be considered your permanent residence address.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1378. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

IMPORTANT Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.