What is your current Medicare number?

When you enter your Medicare number below, your Medicare eligibility will be verified using data from the Centers for Medicare & Medicaid Services (CMS). If you are not currently eligible for Medicare, your application may be denied.

Medicare Number*

This is an 11 digit number

Do you have other prescription drug coverage (like VA, TRICARE) in addition to Elderplan?YesNo

Personal Information

First Name*

Middle Initial

Last Name*

Birth date*

Gender*MaleFemale

Do you work?*YesNo

Marital Status*MarriedSingleDivorcedWidowed

What is your primary address?

Street Address*

Street Address Line 2

City*

State*New York

County*BronxDutchessKingsLivingstonMonroeNassauNew YorkOntarioOrangeOrleansPutnamQueensRichmondRocklandSenecaSuffolkUlsterWestchesterYatesOnondaga

Zip / Postal Code*

Is your mailing address the same as your primary address?*YesNo

What is your phone number?

Home Phone*

This is a 10-digit number.

Cell Phone

This is a 10-digit number.

I don't have an email address.

Did you receive any Veterans Benefits:*YesNo

Preferred Language

Select one if you prefer to speak in a language other than English:*I prefer to speak in EnglishSpanishChineseOther - specify

Select one if you want us to send you information in a language other than English.*I prefer information in EnglishSpanishChineseOther - specify

Would you prefer plan information in an accessible format?BrailleLarge printAudio CDNo Thanks

Tell us about your current doctor and clinic.

Name of Primary Care Physician (PCP)

Name of Clinic

Health Center

By clicking the 'Agree' button below, I agree and understand that:

• I am enrolling in

  Elderplan Extra Help(HMO-POS)

  Elderplan Flex(HMO-POS) Plan

  the Medicaid Beneficiaries (HMO-POS D-SNP) Plan

• To stay in Elderplan, I must keep both Hospital (Part A) and Medical (Part B).

• By joining this Medicare Advantage (MA) Plan, I acknowledge that Elderplan will share my information with Medicare, who may use it to track my enrollment, make payments, and for other purposes allowed by Federal law that authorize collecting this information (see Privacy Act Statement below).

• 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 and MA MSA plans).

• I understand that when my Elderplan coverage begins, I must get all my medical and prescription drug benefits from Elderplan. Benefits and services provided by Elderplan and contained in my Elderplan "Evidence of Coverage" document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Elderplan will pay for benefits or services that are not covered.

• The information on this enrollment form is accurate to the best of my knowledge. I understand that if I knowingly 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.

• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

Have you read and do you agree to the enrollment agreement?Agree

If I sign as an authorized representative, it means I have the legal right under state law to sign.

Electronic Signature

Please type your name as your electronic signature.

Full Name*

Today's Date*

Please review your application before submitting.

When you click "Submit application" below you are providing your e-signature (or the e-signature of your authorized representative). If signed by an authorized representative (as described above), this e-signature certifies that:

1. This person is authorized under the laws of the state where you live to complete this enrollment and

2. Documentation of this authority is available upon request from Medicare.

It means that you have read and understood the information on this form.

Please note that once you submit your application, you will no longer be able to make edits online.

By submitting your enrollment application, you are:

• Providing your electronic signature

• Submitting your enrollment application electronically

• Consenting to online contracting through the Internet

• Consenting to receive future communications from us online through the Internet, including mail

• Offering to purchase a product from Elderplan

• Acknowledging and agreeing with the above statements

You will not be enrolled until your application has been reviewed and accepted.

Print a copy of my application