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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.
IMPORTANTDo 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.
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.
If none of these statements applies to you or you’re not sure, please contact Centers Plan for Healthy Living at 1-(877)-940-9330 (TTY Users should call 711) to see if you are eligible to enroll. We are open Monday-Sunday 8 am to 8 pm.
By checking any of the following boxes above, and signing this form you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period.
To enroll in a Centers Plan for Healthy Living Plan, Please provide the following Information.
Permanent Residence Street Address (P.O. Box is not allowed):
If the answer is "yes" please provide the following information:
By entering your name in the signature box below, you agree to enroll in a Centers Plans for Healthy Living Plan and agree to the release and authorization language stated in the application. You also agree that the information that you are providing is accurate.
Please type your name as your electronic signature
If you are the authorized representative and/or have POWER OF ATTORNEY (POA), you must sign below and provide the following information along with your POA form:
Please contact Centers Plan for Healthy Living at 1-877-940-9330 if you need information in an accessible format other than what's listed above. Our office hours are 8 am-8 pm, 7 days a week. TTY users can call 711.
List your Primary Care Physician (PCP), clinic, or health center:
Please contact Centers Plan for Healthy Living at 1-877-940-9330 if you want to get one of these materials by email. Our office hours are 8am-8pm, 7 days a week. TTY users can call 711.
Emergency Contact:
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 having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.
If you have to pay a Part D Income Related Monthly Adjustment Amount (Part D IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON'T pay Centers Plan for Health Living the Part D-IRMAA.
If you don’t select a payment option, you will get a bill each month.