Enrollment Enrollment Form 1Enrollment Information2Required Information3Medicare & Other Coverage4Acknowledgement & Signature EXHIBIT 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN A MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE PRESCRIPTION DRUG PLAN (PART D) Who can use this form? People with Medicare who want to join a Medicare Advantage Plan or Medicare Prescription Drug PlanTo join a plan, you must: Be a United States citizen or be lawfully present in the U.S. Live in the plan’s service area Important: To join a Medicare Advantage Plan, you must also have both: Medicare Part A (Hospital Insurance) Medicare Part B (Medical Insurance) When do I use this form? You can join a plan: Between October 15–December 7 each year (for coverage starting January1) Within 3 months of first getting Medicare In certain situations where you’re allowed to join or switch plans Visit Medicare.gov to learn more about when you can sign up for a plan. What do I need to complete this form? Your Medicare Number (the number on your red, white, and blue Medicare card) Your permanent address and phone number Reminders: 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. Your plan will send you a bill for the plan’s premium. 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. What happens next? Send your completed and signed form to:Signature Advantage12201 Bluegrass ParkwayLouisville, KY 40299Once they process your request to join, they’ll contact you. How do I get help with this form? Call Signature Advantage at 844-214-8633. TTY users can call 711. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. En español: Llame a Signature Advantage al 844-214-8633 TTY 711 o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.Note:You must complete all items in Section 1. The items in Section 2 are optional — you can’t be denied coverage because you don’t fill them out. According 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. The valid OMB control number for this information collection is 0938-NEW. 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 needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions 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. IMPORTANT: Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan. Section 1All fields on this page are required (unless marked optional)Select the plan you want to join* Signature Advantage Plan - $29.60/per month Signature Advantage Community - $29.60/per month Name* First Name Middle Initial Last Name Birth date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex* Female Male Phone number*Email* Preferred Contact Method* Phone Email Permanent Resident street address (Don't enter a PO Box)* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address*Do you recieve your mail at a different address? Or have a PO Box? Yes No Mailing Address*If your mailing address is different from your permanent address, or if you would like to use a PO Box, please input that information here. Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Medicare InformationDo you have Medicare?* Yes No Medicare Number*Answer these important questionsWill you have other prescription drug coverage (like VA, TRICARE) in addition to Signature Advantage?* Yes No Name of other coverage* Member number for this coverage* Group number for this coverage* Are you a resident in a long-term are facility, such as a nursing home or assisted living facility?* Yes No Facility name* Facility address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Are you enrolled in your State Medicaid program?* Yes No Medicaid number* Please read & sign belowRelease of InformationBy joining this Medicare health plan, I acknowledge that Signature Advantage will release my information to Medicare and other parties as is necessary for treatment, payment and health care operations. I also acknowledge that Signature Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations.I must keep both Hospital (Part A) and Medical (Part B) to stay in Signature Advantage.By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Signature Advantage 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).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 Signature Advantage coverage begins, I must get all of my medical and prescription drug benefits from Signature Advantage. Benefits and services provided by Signature Advantage and contained in my Signature Advantage “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Signature Advantage will pay for benefits or services that are not covered.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.Signature*Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you a authorized representative signing for someone else?* Yes No If signed by an authorized representative (as described above), this signature certifies that:This person is authorized under State law to complete this enrollment* Yes Documentation of this authority is available upon request by Medicare* Yes Name* First M Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Relationship to enrollee* CAPTCHACAPTCHA is not case-sensitive.
