Permanent Residence Street Address (P.O. Box is not allowed):
Mailing Address (only if different from your Permanent Residence Address):
Emergency Contact Information:
Medicare Health Insurance
Paying Your Plan Premium
You can pay your monthly plan premium including any late enrollment penalty that you currently have or may owe by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.
If you are assessed a Part D-Income Related Monthly Adjustment Amount(IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay PruittHealth Premier the Part D-IRMAA.
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.
If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.
If you don’t select a payment option, you will get a bill each month.
If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis, otherwise we may need to contact you to obtain additional information.
If “yes”, please list your other coverage and your identification (ID) number(s) for this coverage:
If “yes,” please provide the following information:
If yes, please provide the following information:
Please choose the name of a Primary Care Physician (PCP), clinic or healthcare center:
Please Read This Important Information
If you currently have health coverage from an employer or union, joining PruittHealthPremier could affect your employer or union health benefits. You could lose your employer or union health coverage if you join PruittHealth Premier. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.
By completing this enrollment application, I agree to the following:
PruittHealth Premier is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.
PruittHealth Premier serves a specific service area. If I move out of the area that PruittHealth Premier serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of PruittHealth Premier, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from PruittHealth Premier when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. 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.
I understand that beginning on the date PruittHealth Premier coverage begins, I must get all of my health care from PruittHealth Premier except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by PruittHealth Premier and other services contained in my PruittHealth Premier Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered.
Without authorization, NEITHER MEDICARE NOR PRUITTHEALTH PREMIER 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 PruittHealth Premier, he/she may be paid based on my enrollment in PruittHealth Premier.
Release of information: By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that PruittHealth Premier 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 State law 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 by PruittHealth Premier or by Medicare.
If you are the authorized representative, you must sign above and provide the following information:
Please be advised that by proceeding you are sending an actual enrollment request to PruittHealth Premier (HMO SNP).
Review the Plan's
2020 Enrollment Documents.