CPHL Enrollment

2022 English Enrollment

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Enrollment Year: 2022

OMB No. 0938-1378
Expires:7/31/2023

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 Health Living
75 Vanderbilt Avenue
Suite 700
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 Health 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 Health Living al 1-877-940-9330/TTY 711.
O, a llamar Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estara disponible para asistirle. Los usuarios de TTY pueden llamar 1-877-486-2048.
Enrollment Year: 2022

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.

Enrollment Year: 2022

Please contact Centers Plan for Healthy Living (CPHL), if you need information in another language or format (Braille)


Enrollment Year: 2022

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):



Emergency Contact:

Enrollment Year: 2022

Please provide Medicare insurance information


Enrollment Year: 2022

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 Health Living the Part D-IRMAA.

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

Payment option


Enrollment Year: 2022

Prescription drug coverage


Medicare and Medicaid ONLY


For I-SNP ONLY


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




List your Primary Care Physician (PCP), clinic, or health center: