MAP Individual Enrollment Request Form Step 1 of 4 25% Section 1 - All fields on this page are required (unless marked optional)Select the plan you want to join:(Required) Community First Health Plans Medicare Advantage Alamo Plan (HMO) (Community First MAPD Standard Plan (HMO) H5447-001) Community First Health Plans Medicare Advantage Dual Eligible Special Needs Plan (HMO D-SNP) (Community First MAPD D-SNP Standard Plan (HMO D-SNP) H5447-002) Name(Required) First Last Birth Date(Required) MM slash DD slash YYYY Sex:(Required) Male Female Phone Number:(Required)Email(Required) Permanent Residence street address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Mailing address, if different from your permanent address (PO Box allowed) Street Address City State / Province / Region ZIP / Postal Code Your Medicare Information:Medicare Number:(Required)Please Answer These Important Questions:Will you have other prescription drug coverage (like VA, TRICARE) in addition to Community First Medicare Advantage Alamo Plan or D-SNP?(Required) Yes No Name of other coverage:(Required)Member number for this coverage:(Required)Group number for this coverage:(Required)Please complete this section only if Community First MAPD D-SNP Standard Plan (HMO D-SNP) H5447-002 is selected. (All must be Yes to be eligible.)1. Are you entitled to Medicare Part A?(Required) Yes No 2. Are you enrolled in Medicare Part B?(Required) Yes No 3. Are you enrolled in the Texas Health and Human Services Medicaid program?(Required) Yes No 4. Please enter your Medicaid ID number printed on Your Texas Benefits Member ID card.(Required)IMPORTANT: Read and sign below:• I must keep both Hospital (Part A) and Medical (Part B) to stay in Community First Health Plans Medicare Advantage Alamo Plan or D-SNP.• By joining this Medicare Advantage Plan, I acknowledge that Community First Health Plans 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 Medicare Advantage plan at a time – and that enrollment in this plan will automatically end my enrollment in another Medicare Advantage plan (exceptions apply for MA PFFS, MA MSA plans).• I understand that when my Community First Medicare Advantage Alamo Plan or D-SNP coverage begins, I must get all of my medical and prescription drug benefits from Community First Medicare Advantage Alamo Plan or D-SNP. Benefits and services provided by Community First Medicare Advantage Alamo Plan or D-SNP and contained in my Community First Medicare Advantage Alamo Plan or D-SNP “Evidence of Coverage” document (also known as a “member contract” or “subscriber agreement”) will be covered. Neither Medicare nor Community First Medicare Advantage Alamo Plan or D-SNP 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, and2. Documentation of this authority is available upon request by Medicare.SignatureToday's date(Required) MM slash DD slash YYYY If you're the authorized representative, sign above and fill out these fields: Name First Last Phone NumberAddressRelationship to EnrolleeIf the application is being submitted by an agent: This form was submitted over the phone by an agent. The Member has been read and verbalized understanding of the information on this form on a recorded line. This form was submitted in person with an agent. The Member signed the form in person with a wet signature. Agent NameNational Producer NumberAgent Email Section 2Answering these questions is your choice. You can't be denied coverage because you don't fill them out.Select one if you want us to send you information in a language other than English.(Required) Spanish No translation needed Select one if you want us to send you information in an accessible format.(Required) No accessibility format(s) needed Braille Large print Audio CD Data CD Please contact Community First Medicare Advantage Plan at 210-358-6386 or 1-833-434-2347 (toll-free) if you need information in an accessible format other than what is listed above. Our office hours are 7 days a week from 8 a.m. to 8 p.m. (October 1 – March 31); Monday through Friday, from 8 a.m. to 8 p.m. (April 1 – September 30). Message service available on weekends and holidays from April 1 – September 30. TTY users can call 711, 24 hours a day/7 days a week.Do you work? Yes No I choose not to answer Does your spouse work? Yes No I choose not to answer List your Primary Care Provider (PCP), clinic, or health center:PCP ID#:Name of PCP:I want to get the following materials via email. Select one or more. Summary of Benefits Evidence of Coverage (EOC) Email address: PRIVACY ACT STATEMENTThe 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 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.Proposed Effective Date:(Required) MM slash DD slash YYYY Agent Name(Required)National Producer Number:(Required)Agent Email(Required) Attestation of Eligibility for an Enrollment PeriodTypically, 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.Attestation 1 I am new to Medicare. Attestation 2 I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP). Attestation 3 I recently moved outside of the service area for my current plan or I recently moved and this is a new option for me. I moved on (insert date):(Required) MM slash DD slash YYYY Attestation 4 I recently was released from incarceration. I was released on (insert date):(Required) MM slash DD slash YYYY Attestation 5 I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date):(Required) MM slash DD slash YYYY Attestation 6 I recently obtained lawful presence status in the United States. I got this status on (insert date):(Required) MM slash DD slash YYYY Attestation 7 I recently had a change in my Medicaid (newly received Medicaid, had a change in level of Medicaid assistance, or lost Medicaid). I had a change in my Medicaid on (insert date):(Required) MM slash DD slash YYYY Attestation 8 I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly received Extra Help, had a change in the level of Extra Help, or lost Extra Help). I had a change in my Extra Help on (insert date):(Required) MM slash DD slash YYYY Attestation 9 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 have not had a change. Attestation 10 I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility). I moved/will move into/out of the facility on (insert date):(Required) MM slash DD slash YYYY Attestation 11 I recently left a PACE program. I left a PACE program on (insert date):(Required) MM slash DD slash YYYY Attestation 12 I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare's). I lost my drug coverage on (insert date):(Required) MM slash DD slash YYYY Attestation 13 I am leaving employer or union coverage I am leaving employer or union coverage on (insert date):(Required) MM slash DD slash YYYY Attestation 14 I belong to a pharmacy assistance program provided by my state. Attestation 15 My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan. Attestation 16 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):(Required) MM slash DD slash YYYY Attestation 17 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):(Required) MM slash DD slash YYYY Attestation 18 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. Other:If none of these statements apply to you or you are not sure, please contact Community First Medicare Advantage Plan at 1-833-434-2347 (toll-free) or 210-358-6386 (local) to see if you’re eligible to enroll. You can call 7 days a week, from 8 a.m. to 8 p.m. (October 1 – March 31); Monday through Friday, from 8 a.m. to 8 p.m. (April 1 – September 30). Message service is available on weekends & holidays from April 1 – September 30. TTY users can call 711, 24 hours a day/7 days a week. For Agents OnlyNote: This page must be completed in its entirety to prevent the delay or denial of the enclosed application. Proposed Coverage Start Date MM slash DD slash YYYY Select Enrollment Period ICEP (MA or MAPD) IEP (PDP of MAPD) OEP SEP AEP OEPI SEP Code (Required if SEP selected)(Required)SEP Date(Required) MM slash DD slash YYYY Licensed Sales Agent NameLicensed Sales Agent IDLicensed Sales Agent Phone NumberScope of Appointment ID NumberAppointment TypeDate MM slash DD slash YYYY Δ
