2022 Lycoming Tioga MA Kit

OFFICE USE ONLY Name of Staff Member/Agent/Broker (if assisted in enrollment): Plan ID#: Effective Date of Coverage: ICEP/IEP: AEP: SEP (type): Not Eligible: If you assisted with this application, sign and date here: Broker Received Date and Notes: ___________________________________________________________ Agent/Broker Code: __________________ Application Mailed/Faxed:____________________________________________________________ Y0069_221136_C Copyright 2021 UPMC Health Plan Inc.All rights reserved. 2022_MCINDSUSQPRM_21MCID1948 (RT) 8/15/21 IMPORTANT: Signature required below: • I must keep both Hospital (Part A) and Medical (Part B) to stay in UPMC for Life . • By joining this Medicare Advantage plan, I acknowledge that UPMC for Life will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below). • 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. • Once I am a member of UPMC for Life , I have the right to appeal plan decisions about payment or services if I disagree. • Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan. • 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 people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border. • I understand that when my UPMC for Life coverage begins, I must get all of my medical and prescription drug benefits from UPMC for Life . Benefits and services provided by UPMC for Life and contained in my UPMC for Life “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor UPMC for Life will pay for benefits or services that are not covered. • I understand and agree to abide by the rules of UPMC for Life . • 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 Signature: Today’s date: If you’re the authorized representative, sign above and fill out these fields: Name: Address: Phone Number: Relationship to Enrollee: Page 5 of 5 Enrollment 129 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111