Who is Authorized to Disclose Information
By joining this Medicare Advantage plan, I acknowledge that Providence Medicare Advantage Plans will release my information to Medicare and other plans as is necessary for treatment, health care operations. I also acknowledge that Providence Medicare Advantage Plans will release my information including my prescription drug event data if I am on a prescription drug plan to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. 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 authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 from Medicare.
Statements of Understanding
Providence Medicare Advantage Plans is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or maybe get in the future. I understand that if I don't have Medicare prescription drug coverage, or a creditable prescription drug coverage plan (as good as Medicare's), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year, when an enrollment period is available (Example: October 15th-December 7th of every year), or under certain special circumstances.
Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
Providence Medicare Advantage Plans serves a specific service area. If I move out of the area that Providence Medicare Advantage Plans serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Providence Medicare Advantage Plans, I have the right to appeal plan decisions about payment or service if I disagree.
I will read the Evidence of Coverage from Providence Medicare Advantage Plans when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan.
I understand that selecting a Providence Medicare (HMO) plan means that on the date coverage begins, I must get all of my health care from Providence Medicare Advantage Network Providers, except for emergency or urgently needed services or out-of-area dialysis services.
Services authorized by Providence Medicare Advantage Plans and other services contained in my Providence Medicare Advantage Plans Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered provided plan rules are followed. If plan rules are not followed, NEITHER MEDICARE NOR PROVIDENCE MEDICARE ADVANTAGE PLANS WILL PAY FOR THE SERVICES.
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) plans to improve care and for the payment of Medicare benefits. Section 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.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Providence Medicare Advantage Plans, he/she may be paid based on my enrollment in Providence Medicare Advantage Plans.