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Providence Medicare Reverence (HMO-POS)

H9047-035

Plan Premiums

$ 25
00 /month
Monthly Premium

Tell us about yourself

Personal Information
Sex
Required Information

Where do you live?

Permanent Residence Street Address (Don’t enter a PO Box)
Required Information

Who is your primary doctor?

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

Your Medicare information

Medicare Insurance Information
You must have Medicare Part A and Part B to join a Medicare Advantage Plan. Using the information on your Medicare card, please complete the section below.
Required Information

What is your current Medicare situation?

Medicare 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.
Initial Coverage Election Period (ICEP) – Your ICEP begins the first three months before your entitlement to BOTH Part A and Part B and typically ends after the third month of eligibility. (Typically this relates to either your 65th birthday or your 25th month of disability)
Special Election Period (SEP) – You may use an SEP outside of the usual ICEP, IEP, or AEP.
Required Information
Please enter the following
Required Information

Answer these important questions

Important Questions - Please answer the following questions
Will you have other coverage in addition to Providence Medicare Advantage Plans?
Some individuals may have other coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.
Required Information
All fields in this section are optional. Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.
Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.
What’s your race? Select all that apply.
Select one if you want us to send you information in an accessible format.
Please contact Providence Medicare Advantage Plans at 503-574-8000 or 1-800-603-2340 if you need information in an accessible format other than what’s listed above. Our office hours are seven days a week, 8 a.m. to 8 p.m. (Pacific Time). TTY users can call 711.
Do you work?
Does your spouse work?

Information Authorization

Disclosure Overview
Who is Authorized to Disclose Information
Statements of Understanding
Privacy Act Statement
Producer Compensation
Authorization
I authorize the use and disclosure of health information about me as described herein.
Required Information
Relationship
What is the relationship to the person with Medicare listed on this enrollment form?

Add Optional Benefits

Optional Benefit Packages
Optional Dental Benefits - Basic Member pays: $37.50 monthly premium
Would you like to add the Optional Benefit Package #1 to your enrollment?
Optional Dental Benefits - Enhanced Member pays: $53.50 monthly premium
Would you like to add the Optional Benefit Package #2 to your enrollment?
I understand enrollment in the plan listed above is optional. I also understand that I must maintain my coverage in Providence Medicare Advantage Plans in order to be enrolled in the optional supplemental dental plan selected. Additionally, I understand that I must pay the additional optional supplemental dental plan premium in order to maintain my coverage. I will read the optional benefit plan information when I receive it and learn my responsibilities as a member and what services are covered by the plan.
Required Information

Plan Payment

PAYING YOUR PLAN PREMIUM

Please select a payment method
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.

You can pay by credit/debit card or checking/savings account: One-time or recurring payments can be made via your myProvidence account at myProvidence.com or through the Providence website at Providence Health Plan and Providence Health Assurance Premium Payment.
You can pay by phone: Self Service is available 24 hours a day, 7 days a week, at 1-844-791-1468, TTY: 711.

Payment Overview
Extra Help
Late Enrollment Penalty