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 1(800)-421-1220) 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):
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.
If the answer is "yes" please provide the following information:
List your Primary Care Physician (PCP), clinic, or health center: