2022 Lycoming Tioga MA Kit

Page 2 of 5 Section 2—All fields on this page are optional Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out. Select one if you want us to send you information in a language other than English,  Spanish Select one if you want us to send you information in an accessible format.  Braille  Large print  Audio CD Please contact UPMC for Life at 1-877-381-3765 if you need information in an accessible format other than what’s listed above. Our office hours are Oct. 1 through Dec. 7 seven days a week from 7 a.m. to 9 p.m., Dec. 8 through Dec. 31 seven days a week from 8 a.m. to 8 p.m., and Jan.1 through Sept. 30 Monday through Friday from 8 a.m. to 8 p.m. and Saturday from 9 a.m. to 3 p.m. TTY users can call 711. Do you work?  Yes  No Does your spouse work?  Yes  No List your Primary Care Physician (PCP), clinic, or health center: ______________________________ Practice name: _________________________ Practice number: ______________________ Are you a veteran?  Yes  No I want to get the following materials via email.  Annual Notice of Change, Evidence of Coverage, Summary of Benefits, Provider Directory, Prescription Drug Formulary, and Welcome Kit  Explanation of Benefits Email address:_____________________________ Cell phone number: ( _____ ) ________________ By providing your cell phone number and email address, you authorize UPMC Health Plan to contact you regarding your care, member events, plan information, member surveys, and other insurance products. UPMC Health Plan will deliver these messages by email, text messages (including messages by an automatic telephone dialing system), phone calls, and prerecorded phone calls. Standard message and data rates may apply. You can opt out at any time. Enrollment 123 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111