CPHL Enrollment 75 Vanderbilt Ave Staten Island NY 10304 1-844-CPHL-CARES www.centersplan.com

2025 Enrollment English

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Enrollment Year: 2025

Form Information

OMB No. 0938-1378
Expires: 6/30/2026
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 a 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?
Send your completed and signed form to:
Centers Plan for Healthy Living
75 Vanderbilt Avenue
Staten Island, NY 10304

Once they process your request to join, they'll contact you.

How do I get help with this form?
Call Centers Plan for Healthy Living at 1-877-940-9330. TTY users can call 711.

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

En español: Llame a Centers Plan for Healthy Living al 1-877-940-9330/TTY 711.

o, a Medicare gratis al 1-800-633-4227 y oprima el 8 en español y un representante estará disponible para asistirle. Los usuarios de TTY pueden llamar 1-877-486-2048.

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.

H6988_001_002_003_CY25 Enrollment Application_C Approved 8/13/2024

Enrollment Year: 2025

Eligibility

Eligibility Information

Attestation of Eligibility for an Enrollment Period

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.




















Disclaimer

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.

H6988_001_002_003_CY25 Enrollment Application_C Approved 8/13/2024

Enrollment Year: 2025

To enroll in a Centers Plan for Healthy Living Plan, Please provide the following Information.

Permanent Residence street address (Don’t enter a PO Box. Note For individuals experiencing homelessness, a PO Box may be considered your permanent residence address):

Please provide Medicare insurance information

Prescription drug coverage

Medicare and Medicaid ONLY

For I-SNP ONLY

If the answer is "yes" please provide the following information:

H6988_001_002_003_CY25 Enrollment Application_C Approved 8/13/2024

Enrollment Year: 2025

IMPORTANT: Read and sign below:

  • I must keep both Hospital (Part A) and Medical (Part B) to stay in Centers Plan for Healthy Living.
  • By joining this Medicare Advantage, I acknowledge that Centers Plan for Healthy Living 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 people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border
  • I understand that when my Centers Plan for Healthy Living coverage begins, I must get all of my medical and prescription drug benefits from Centers Plan for Healthy Living. Benefits and services provided by Centers Plan for Healthy Living and contained in my Centers Plan for Healthy Living "Evidence of Coverage" document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Centers Plan for Healthy Living 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

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’re the authorized representative, sign above in previous step and fill out these fields below:

H6988_001_002_003_CY25 Enrollment Application_C Approved 8/13/2024

Enrollment Year: 2025

Demographic






















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:

H6988_001_002_003_CY25 Enrollment Application_C Approved 8/13/2024

Enrollment Year: 2025

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 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 Healthy Living the Part D-IRMAA.

If you don’t select a payment option, you will get a bill each month.

For individuals helping Enrollee with completing this form only

Complete this section if you’re an individual (i.e. agents, brokers, SHIP counselors, family members, or other third parties) helping an enrollee fill out this form.

Privacy 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 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.

H6988_001_002_003_CY25 Enrollment Application_C Approved 8/13/2024