OMB No.
0938-1378
Expires: 7/31/2024
®
Individual Enrollment Request Form
Please contact First Choice VIP Care (HMO-SNP) if you need
information in another language or format (for example, Braille).
Who can use People with Medicare who want to join a Medicare Advantage Plan
this form?
To join a plan, Be a United States citizen or be lawfully present in the United States.
you must: 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 You can join a plan:
this form? Between October 15 – December 7 each year (for coverage starting January 1).
Within three months of first getting Medicare.
In certain situations where you’re allowed to join or switch plans.
Visit www.medicare.gov to learn more about when you can sign up for a plan.
What do Your Medicare number (the number on your red, white, and blue Medicare card).
I need to Your permanent address and phone number.
complete Note: You must complete all items in section 1. The items in section 2 are
this form? 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 Send your completed and signed form to:
next? First Choice VIP Care
P.O. Box 7137
London, KY 40742-9732
Once they process your request to join, they’ll contact you.
How do I get Call First Choice VIP Care at 1-833-961-3723. TTY users can call 711.
help with Or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call
this form? 1-877-486-2048.
En español: Llame a First Choice VIP Care al 1-833-961-3723/711 (TTY)
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 If you want to join a plan but have no permanent residence, a Post Office Box, an
experiencing address of a shelter or clinic, or the address where you receive mail (e.g., Social
homelessness 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.
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Individual Enrollment Request Form
SECTION 1 — ALL FIELDS ON THIS PAGE ARE REQUIRED (UNLESS MARKED OPTIONAL).
SELECT THE PLAN YOU WANT TO JOIN:
□ First Choice VIP Care (HMO SNP) — $0 per month
Last First Middle initial □ Mr. □ Mrs.
name: name: (optional): □ Ms.
Birth date: (MM/DD/YYYY) Sex: □ M □ F
Phone number:
Permanent residence
street address (don’t enter a P.O. Box):
City:
County (optional): State: ZIP code:
MAILING ADDRESS (IF DIFFERENT FROM YOUR PERMANENT ADDRESS) (P.O. Box allowed)
Street address:
City: State: ZIP code:
YOUR MEDICARE INFORMATION
Medicare number:
ANSWER THESE IMPORTANT QUESTIONS
Will you have other prescription drug coverage (like VA, TRICARE) in addition to
First Choice VIP Care (HMO-SNP)?
□ Yes □ No
Name of other coverage:
Member number for this coverage:
Group number for this coverage
Are you enrolled in your state Medicaid program?
□ Yes □ No
If “yes,” please provide your Medicaid number:
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Individual Enrollment Request Form
IMPORTANT: READ AND SIGN BELOW
I must keep both hospital (Part A) and medical (Part B) to stay in First Choice VIP Care.
By joining this Medicare Advantage (MA) plan, I acknowledge that First Choice VIP Care will
share my information with Medicare, who may use it to track my enrollment, to make payments,
and for other purposes allowed by federal law that authorize the collection of this information
(see Privacy Act Statement below). Your response to this form is voluntary. However, failure to
respond may affect enrollment in the plan.
I understand that I can be enrolled in only one MA plan at a time – and that enrollment in this
plan will automatically end my enrollment in another MA plan (exceptions apply for MA PFFS,
MA MSA plans).
I understand that when my First Choice VIP Care coverage begins, I must get all of my medical
and prescription drug benefits from First Choice VIP Care. Benefits and services provided by
First Choice VIP Care and contained in my First Choice VIP Care “Evidence of Coverage”
document (also known as a member contract or subscriber agreement) will be covered. Neither
Medicare nor First Choice VIP Care will pay for benefits or services that are not covered.
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 legally authorized to act on my
behalf) on this application means that I have read and understand the contents of this application.
If signed by an authorized representative (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 Medicare.
Signature: Today’s date:
If you’re the authorized representative, sign above and fill out these fields:
Name:
Address:
Phone number: Relationship to enrollee:
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Individual Enrollment Request Form
SECTION 2 — All fields on this page are optional.
Answering these questions is your choice. You can’t be denied coverage because you don’t fill
them out.
Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.
□ No, not of Hispanic, Latino/a, or Spanish origin □ Yes, Mexican, Mexican American, Chicano/a
□ Yes, Puerto Rican □ Yes, Cuban
□ Yes, another Hispanic, Latino/a, or Spanish origin
□ I choose not to answer.
What’s your race? Select all that apply.
□ American Indian or Alaska Native □ Black or African American
Asian: Native Hawaiian and Pacific Islander
□ Asian Indian □ Guamanian or Chamorro
□ Chinese □ Native Hawaiian
□ Filipino □ Samoan
□ Japanese □ Other Pacific Islander
□ Korean □ White
□ Vietnamese □ I choose not to answer.
□ Other Asian
Select one if you want us to send you information in an accessible format.
□ Braille □ Large print □ Audio CD
Please contact First Choice VIP Care at 1-833-961-3723 if you need information in
an accessible format other than what’s listed above. Our office hours are October 1 – March 31:
8 a.m. – 8 p.m., seven days a week; April 1 – September 30: 8 a.m. – 8 p.m., Monday through Friday.
TTY users can call 711.
Do you work? □ Yes □ No
Does your spouse work? □ Yes □ No
List your Primary Care Physician (PCP), clinic, or health center:
Email address:
PRIVACY ACT STATEMENT
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary
enrollment in Medicare Advantage (MA) plans, improve care, and for the payment of Medicare benefits. Sections 1851
and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50 and 422.60 authorize the collection of this information.
CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records
Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is
voluntary. However, failure to respond may affect enrollment in the plan.
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Individual Enrollment Request Form
Office use only:
Name of staff member, agent, or broker (if assisted in enrollment):
Plan ID number: 001 Effective date of coverage:
Application date:
□ ICEP/IEP □ AEP □ SEP □ MA OEP
Not eligible: Other:
NIPR number: Agent ID: Agent writing number:
Agent signature:
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Individual Enrollment Request Form
Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment
period from October 15 through December 7 of each year. There are exceptions that may allow
you to enroll in a Medicare Advantage plan outside of this period.
Please read the following statements carefully and check the box if the statement applies to you.
By checking any of the following boxes, you are certifying that, to the best of your knowledge, you
are eligible for an enrollment period. If we later determine that this information is incorrect, you may
be disenrolled.
□ I am new to Medicare.
□ I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare
Advantage Open Enrollment Period (MA-OEP).
□ I recently moved outside of the service area for my current plan, or I recently moved and this plan
is a new option for me. I moved on (insert date) ___________________.
□ I recently was released from incarceration. I was released on (insert date) ___________________.
□ I recently returned to the United States after living permanently outside of the United States. I
returned to the United States on (insert date) ___________________.
□ I recently obtained lawful presence status in the United States. I got this status on
(insert date) ___________________.
□ I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medical
Assistance, or lost Medicaid) on (insert date) ___________________.
□ I recently had a change in my Extra Help paying for Medicare prescription drug coverage
(newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on
(insert date) ___________________.
□ I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums), or I get
Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.
□ I am moving into, live in, or recently moved out of a long-term care facility (for example, a nursing
home). I moved/will move into/out of the facility on (insert date) ___________________.
□ I recently left a Program of All-Inclusive Care for the Elderly (PACE) on
(insert date) ___________________.
□ I recently involuntarily lost my creditable prescription drug coverage (coverage as good as
Medicare’s). I lost my drug coverage on (insert date) ___________________.
□ I am leaving employer or union coverage on (insert date) ___________________.
□ I belong to a pharmacy assistance program provided by my state.
□ My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
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Individual Enrollment Request Form
□ I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan.
My enrollment in that plan started on (insert date) ___________________.
□ I was enrolled in a special needs plan (SNP), but I have lost the special needs qualification required
to be in that plan. I was disenrolled from the SNP on (insert date) ___________________.
□ I was affected by an emergency or major disaster (as declared by the Federal Emergency
Management Agency (FEMA) or by a federal, state, or local government entity). One of the other
statements here applied to me, but I was unable to make my enrollment request because of
the disaster.
If none of these statements applies to you or you’re not sure, please contact First Choice VIP Care
at 1-833-961-3723 (TTY 711) to see if you are eligible to enroll. We are open October 1 –
March 31: 8 a.m. – 8 p.m., seven days a week, and April 1 – September 30: 8 a.m. – 8 p.m.,
Monday through Friday.
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