If you have any comments concerning the accuracy of the time estimate(s) or sugges- tions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data need- ed, and complete and review the information collection. The valid OMB control number for this information collection is 0938-NEW. Or, call Medicare at 1-800-MEDICARE (1-800-633- 4227). TTY users can call 1-87.Įn español: Llame a Perennial Advantage al 1-88 (TTY 711) 1-86 (TTY 711) 1-88 (TTY 711) 1-88 (TTY 711) 1-88 (TTY 711) 1-88 (TTY 711) 1-88 (TTY 711) 1-88 (TTY 711) o a Medicare gratis al 1-80 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.Īccording to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit. Your plan will send you a bill for the plan’s premium.If you want to join a plan during fall open enrollment (October 15–December 7), the plan must get your completed form by December 7.The items in Section 2 are optional - you can’t be denied coverage because you don’t fill them out. Note: You must complete all items in Section 1. Your permanent address and phone number.Your Medicare Number (the number on your red, white, and blue Medicare card).Visit to learn more about when you can sign up for a plan. In certain situations where you’re allowed to join or switch plans.Within 3 months of first getting Medicare.Between October 15–December 7 each year (for coverage starting January 1).Important: To join a Medicare Advantage Plan, you must also have both: Be a United States citizen or be lawfully present in the U.S.People with Medicare who want to join a Medicare Advantage Plan How to fill out the enrollment form Who can use this form? If Longevity Health Plan decides, based on medical criteria, that your situation is “time-sensitive” or if any physician calls or writes in support of your request for an expedited review, Longevity Health Plan will issue a decision as expeditiously as possible, but no later than seventy-two (72) hours after receiving the request. Longevity Health Plan of Colorado 1-88 (TTY 711).Longevity Health Plan of Michigan 1-88 (TTY 711).Longevity Health Plan of North Carolina 1-88 (TTY 711).Longevity Health Plan of Oklahoma 1-88 (TTY 711).Longevity Health Plan of New York 1-88 (TTY 711).Longevity Health Plan of New Jersey 1-88 (TTY 711).Longevity Health Plan of Illinois 1-88 (TTY 711).Longevity Health Plan of Florida: 1-86 (TTY 711).You may file an expedited appeal by calling: You, your doctor, or your representative can do this. Start by calling, writing, or faxing our plan to make your request for us to authorize or provide coverage for the medical care you want. If your health requires a quick response, you must ask for a “fast appeal. Any physician or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider) acting on behalf of the enrollee.The enrollee’s treating physician acting on behalf of the enrollee* or staff of physician’s office acting on said physician’s behalf (e.g., request is on said physician’s letterhead or otherwise indicates staff is working under the direction of the provider).
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |