Keep a copy of this form for your records CareAdvantage Cal MediConnect Plan (Medicare–Medicaid Plan) Application Form To join HPSM CareAdvantage Cal MediConnect Plan (Medicare–Medicaid Plan), you must have Medicare Part A, Medicare Part B, and Medi-Cal through the Health Plan of San Mateo (HPSM). You can also call 1-888-252-3153 to join CareAdvantage CMC. The call is free. Tell us about yourself: __________________________________ ______________________ First Name Middle ___ ___ / ___ ___ / ___ ___ ___ ___ Date of Birth (mm/dd/year) Male Female Sex (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Phone number __________________________________ Last Name _______________________________________ Email Address: (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Another phone number Address where you live: __________________________________________ ___________________ ____ _______ ______________ Address City State Zip Code County (Optional) Address where you get mail (if different from where you live): __________________________________________ ___________________ ____ _______ ______________ Address City State Zip Code County (Optional) _______________________________________________ Emergency contact name (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Emergency contact phone If you are not a native English speaker, you can call 1-888-252-3153 to get the form in a different language. TTY users should call 1-800-735-2929 or dial 7-1-1 (California Relay Service). What is your preferred language? Speak: English Spanish Tagalog Chinese Russian Other: ___________________ Read : Spanish Tagalog Chinese Russian Other: ___________________ English Do you want us to send you materials in this language? Yes No Do you want us to send you materials in other formats? Please specify type: Large Print Braille Audio Tape Other: _________________________ Tell us where you usually get health services: _______________________________________________________ (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Name of your primary care provider, clinic, or health center Phone number Tell us about your Medicare and Medi-Cal coverage: Fill in your Medicare and Medi-Cal information below. You can find this information on your red, white, and blue Medicare card, or a letter from Social Security or the Railroad Retirement Board. Also, please put your Medi-Cal ID number as it appears on the front of your card. SAMPLE ONLY SAMPLE ONLY Name: Medicare Claim Number Sex __ __ __ - __ __ - __ __ __ __ Is Entitled To __ Effective Date Hospital (Part A) Medical (Part B) Medicare Number: _____________________ Medi-Cal ID No: ___________________________ Other personal information: Do you have End-Stage Renal Disease (ESRD)? Yes No If “yes” and you’ve had a successful kidney transplant and/or no longer need regular dialysis, please attach a note from your doctor. Do you live in a long-term care facility? Yes No If yes, fill in the information below: _______________________________________________________ (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Name of the facility Phone number Your health coverage including your prescription drug coverage: Some people have other health insurance or drug coverage through private insurance, TRICARE, Employers, Unions, Veterans Affairs, or the State Pharmaceutical Assistance Programs. Do you have other health coverage in addition to Medicare and Medi-Cal? Yes No If yes, fill in the information below: Name of your plan (and employer, if applicable) Group number: ID number: 1 2 3 4 5 If you have health coverage from an employer or union or other private or public health insurance right now, you will not be able to join CareAdvantage CMC Please read and sign below. When you sign this form, it means that you understand: • HPSM CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan) has a contract with the federal government and with the State of California. • The health services you get with your new plan may be different than the services you had before. • I must keep Medicare Part A, Part B and have MediCal through the Health Plan of San Mateo (HPSM). • I can be in only one Medicare plan at a time. • By joining CareAdvantage CMC, I will end my enrollment in another Medicare health or prescription drug plan. • I must tell CareAdvantage CMC about any prescription drug coverage that I have or may get in the future. • If I move, I need to tell CareAdvantage CMC. • As a member of CareAdvantage CMC, I have the right to appeal if I don’t agree with CareAdvantage CMC’s decisions about payment or services. • The CareAdvantage CMC doesn’t usually cover people while they’re out of the country. • On the date CareAdvantage CMC coverage begins, I must get my health care from CareAdvantage CMC doctors, except for emergency or urgently needed care, out-of-area dialysis or if I get CareAdvantage CMC approval to see other providers in some circumstances. • If I need to see a doctor or other provider who is not in CareAdvantage CMC, I may need prior authorization or I may have to pay out-of-pocket for the services I get. • I understand that if a sales agent, broker, or other individual employed by or contracted with CareAdvantage CMC is helping me, CareAdvantage CMC may pay that person when they enroll me. • By joining CareAdvantage CMC, I know that CareAdvantage CMC may share my information with Medicare and Medi-Cal and other plans as necessary for treatment, payment, and health care operations. • I understand that prescription drugs are covered, but not always the same ones I’m already taking. I understand that I’ll be able to receive at least one 30-day supply of the prescription drugs I currently take anytime during the first 90 days of coverage in CareAdvantage CMC. I understand that I may be able to continue seeing the doctors I go to now for a period up to twelve (12) months for Medicare services and a period of up to twelve (12) months for Medi-Cal services from the effective date of enrollment in CareAdvantage CMC. I must contact CareAdvantage CMC for information on how to do this. I further understand that CareAdvantage CMC has providers and pharmacies I must use to get health care services, except for non-routine, emergency situations. • I know that CareAdvantage CMC may share my information including my prescription drug information with Medicare and Medi-Cal. They may release it for research and other purposes, as allowed by Federal statutes and regulations. • The information on this form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I’ll be disenrolled from CareAdvantage CMC. • My signature (or my authorized representative’s signature) on this form means that I’ve read and understood this form. If an authorized representative signs, the person’s signature means that he or she is authorized under State law to complete this enrollment, and documentation of this authority is available upon request from Medicare or Medi-Cal. _________________________________________________________ Your Signature: ___ ___ / ___ ___ / ___ ___ Date: If you are the authorized representative, you must provide the following information, sign, and date below: _________________________________________________ Name (Please print) ________________________________________ Signature ______________________________________________________________________________________________ Address ___________________________________________________ Relationship to Enrollee (___ ___ ___) ___ ___ ___ - ___ ___ ___ ___ Phone number ___ ___ / ___ ___ / ___ ___ Today’s Date: For more information, visit www.hpsm.org/CareAdvantage. If you have questions, call a licensed CareAdvantage CMC sales representative at 888-252-3153, Monday through Friday 9:00 a.m. to 6:00 p.m. TTY users should call 800-735-2929 or dial 7-1-1 (California Relay Service). The call is free. This information is available for free in other languages and formats like Braille or audio CD. Para más información, visite www.hpsm.org/careadvantage. Si tiene alguna pregunta, llame a un representante de ventas de CareAdvantage CMC autorizado al 1-888-252-3153, de lunes a viernes de 9:00 a.m. a 6:00 p.m. Los usuarios de TTY deben llamar al 1-800-735-2929 o marcar 7-1-1. (California Relay Service). La llamada es gratuita. Esta información está disponible gratis en otros idiomas y formatos como Braille o CD de audio. 欲 了 解 更 多 資 訊 ， 請瀏覽 w w w.h p sm.org/ car eadvantage。如果您有任何疑問，請致電 與 獲 授 權 的 CareAdvantage CMC 銷售代表聯絡 888-252-3153, 服務時間為週一至週五上午 9:00 至晚上 6:00 。 TT Y 使用者應致電 800-735-2929 或撥打 7-1-1。(California Relay Ser vice)。 該電話是免費電話 。 此 信 息 是 免 費 提 供 其他語言和格式，如盲文或音頻 CD 。 Bumisita sa www.hpsm.org/careadvantage para sa karagdagang impormasyon. Kung mayroon kang mga katanungan, tumawag sa isang lisensiyadong kinatawan CareAdvantage CMC pagbebenta sa 888-252-3153, Lunes hanggang Biyernes 9:00-6:00 Ang mga gumagamit ng TTY ay dapat tumawag sa 800-735-2929 o i-dial ang 7-1-1. (California Relay Service). Ang tawag ay libre. Ang impormasyon na ito ay magagamit nang libre sa iba pang mga wika at mga format tulad ng Braille o audio CD. Более подробные сведения представлены на веб-сайте www.hpsm.org/careadvantage. Если у вас есть вопросы, вызовите квалифицированного CareAdvantage CMC торговым представителем в 888-252-3153, с понедельника по пятницу с 9:00 до 6:00 вечера. Пользователям телетайпа (TTY) следует звонить по номеру 800-735-2929 или набирать 7-1-1. (California Relay Service). Звонки по этому номеру бесплатные. Эта информация доступна бесплатно на других языках и форматы, такие как Брайля или аудио компакт-диска. We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-866-880-0606. Someone who speaks English can help you. This is a free service. English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an Spanish: interpreter, just call us at 1-866-880-0606. Someone who speaks English can help you. This is a free service. Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Spanish: Tenemos servicios de que intérprete sin costo alguno para Este responder cualquier pregunta que pueda 1-866-880-0606. Alguien hable español le podrá ayudar. es un servicio gratuito. tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-866-880-0606. Chinese Mandarin: Alguien que hable español le podrá ayudar. Este es un servicio gratuito. 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致 Mandarin: 电Chinese 1-866-880-0606。我们的中文工作人员很乐意帮助您。这是一项免费服务。 我們提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要此翻译服务，请致 电 1-866-880-0606。我們的中文工作人员很乐意帮助您。这是一项免费服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 Chinese Cantonese: 1-866-880-0606。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-866-880-0606。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan Tagalog: sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, ninyo hinggil Mayroonlamang kamingkami libreng serbisyo sa pagsasaling-wika upang masagotngang anumang mga katanungan ninyo tawagan sa 1-866-880-0606. Maaari kayong tulungan isang nakakapagsalita ng Tagalog. sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang Itohinggil ay libreng serbisyo. kami sa 1-866-880-0606. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. Russian: Russian: возникнут вопросы относительно страхового или медикаментного плана, вы можете Если у вас Если у вас относительно или медикаментного плана, выуслугами можете воспользоватьсявозникнут нашими вопросы бесплатными услугамистрахового переводчиков. Чтобы воспользоваться воспользоваться нашими услугами переводчиков. Чтобы воспользоваться переводчика, позвоните нам бесплатными по телефону 1-866-880-0606. Вам окажет помощь сотрудник, услугами который переводчика, позвоните нам побесплатная. телефону 1-866-880-0606. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга говорит по-pусски. Данная услуга бесплатная. French: French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à Nousrégime proposons des services gratuits d’interprétationPour pouraccéder répondreauà service toutes vos questions relatives notre notre de santé ou d'assurance-médicaments. d'interprétation, il vousà suffit régime de santé ou d’assurance-médicaments. Pour accéder au service d’interprétation, il vous suffit de de nous appeler au 1-866-880-0606. Un interlocuteur parlant Français pourra vous aider. Ce servicenous est appeler au 1-866-880-0606. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. gratuit. Vietnamese: Vietnamese: Chúngtôitôicócódịch dịchvụvụthông thôngdịch dịchmiễn miễnphí phíđể đểtrả trảlời lời các cáccâu câuhỏi hỏivề về chương chương sức sức khỏe khỏe và và chương trình thuốc Chúng men. Nếuquí quívịvịcần cầnthông thôngdịch dịchviên viên xin xin gọi tiếng Việt giúpgiúp đỡ quí vị. Đây men. Nếu gọi 1-866-880-0606 1-866-880-0606sẽsẽcócónhân nhânviên viênnói nói tiếng Việt đỡ quí vị. là dịch vụ vụ miễn phíphí . . Đây là dịch miễn German: German: Unser kostenloser kostenloser Dolmetscherservice beantwortet Ihren Fragen unseremzu GesundheitsArzneimittelplan. Unser Dolmetscherservice beantwortet Ihren zuFragen unserem und Gesundheitsund Unsere Dolmetscher erreichen Sie unter 1-866-880-0606. wird Ihnen dortMan auf Deutsch weiterhelfen. Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man 1-866-880-0606. wird Ihnen dort auf Dieser Service ist kostenlos. Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: Korean: 당사는의료 의료보험 보험또는 또는약품 약품보험에 보험에관한 관한질문에 질문에답해 답해드리고자 드리고자무료 무료통역 통역서비스를 서비스를 제공하고 제공하고 있습니다. 있습니다. 당사는 통역서비스를 서비스를이용하려면 이용하려면 전화 1-866-880-0606 주십시오. 한국어를 하는하는 담당자가 도와 통역 1-866-880-0606번으로 번으로문의해 문의해 주십시오. 한국어를 담당자가 드릴 것입니다. 이 서비스는 무료로 운영됩니다. 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Arabic: Arabic: اننإ مدقن تامدخ مجرتملا يروفلا ةباجإلل ،مترجم فوري للحصول على .األدوية لدينا بالصحة أو جدول ةيناجملا أي أسئلة تتعلق الفوري المجانية لإلجابة عن نعخدمات المترجم إننا نقدم ةلئسأ يأ قلعتت ةحصلاب وأ لودج ةيودألا انيدل. لوصحلل سيقوم شخص ما يتحدث العربية.6868-866-666-1 هذه خدمة مجانية ليس عليك سوى االتصال بنا على.بمساعدتك. يروف مجرتم ىلع، ىلع انب لاصتالا ىوس كيلع سيل1-866-880-0606. كتدعاسمب ةيبرعلا ثدحتي ام صخش موقيس. ةيناجم ةمدخ هذه. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano Italian: e farmaceutico. Perinterpretariato un interprete, gratuito contattare numero 1-866-880-0606. Un nostro che Èsanitario disponibile un servizio di peril rispondere a eventuali domande sulincaricato nostro piano parla Italianovi fornirà l’assistenza necessaria. È un servizio gratuito. sanitario e farmaceutico. Per un interprete, contattare il numero 1-866-880-0606. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca Portugués: do nosso de plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através número Dispomos serviços de interpretação gratuitos para responder a qualquer questão que tenhado acerca do 1-866-880-0606. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-866880-0606. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou French Creole: an. Pou jwenn yonentèprèt entèprèt,gratis jis rele noureponn nan 1-866-880-0606. Yon mounkonsènan ki pale Kreyòl edeoswa w. Sadwòg a se Nou genyen sèvis pou tout kesyon ou ta genyen plankapab medikal yon an. sèvis ki gratis. nou Pou jwenn yon entèprèt, jis rele nou nan 1-866-880-0606. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na Polish: temat planu zdrowotnego lub dawkowania leków. Aby pomocy tłumacza znającego język polski, Umożliwiamy bezpłatne skorzystanie z usług tłumaczaskorzystać ustnego, zktóry pomoże w uzyskaniu odpowiedzi na należy planu zadzwonić pod numerlub 1-866-880-0606. Ta usługa bezpłatna. temat zdrowotnego dawkowania leków. Aby jest skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-866-880-0606. Ta usługa jest bezpłatna. Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दुभाषिया Hindi: सेवाएँ स्वास््य उपलब्ध या हैं. एक भाषिया प्राप्त करनेमेंकेआपक लिए,े बस परने फोन करें. हमारे कोई व्यक्ति हमारे दवा दुकी योजना के बारे ककसीहमेंभी1-866-880-0606 प्रश्न के जवाब दे के लिए पास मुफ्जो त आपकी मदद कर दसकता यह एक सेवा है . हमें 1-866-880-0606 पर फोन करें . कोई दहिन्दी भ सेवाएँहै उपिब्ध हैं. एक भ करनेमुफ्कत े लिए, बस ु ाषियाबोलता ु ाषियाहै.प्राप्त व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है . यह एक मुफ्त सेवा है . Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために、無料の通訳サービスが Japanese: ありますございます。通訳をご用命になるには、1-866-880-0606 にお電話ください。日本語を話す人 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために、無料の通訳サービス 者 が支援いたします。これは無料のサービスです。 がありますございます。通訳をご用命になるには、1-866-880-0606 にお電話ください。日本語を話 す人者が支援いたします。これは無料のサービスです。 Armenian: Մենք ունենք անվճար բանավոր թարգմանչական ծառայություններ՝ առողջապահական կամ Armenian: դեղերի ծրագրի մասինբանավոր ձեր ունեցած որևէ հարցերին պատասխանելու համար:Բանավոր Մենք ունենք անվճար թարգմանչական ծառայություններ՝ առողջապահական կամ հեռախոսահամարով: թարգմանիչ խնդրելու համար զանգահարեք դեղերի ծրագրի մասին ձեր պարզապես ունեցած որևէ հարցերին1-866-880-0606 պատասխանելու համար:Բանավոր Հայերեն խոսացող որևէ անձ կօգնի ձեզ:Այս ծառայությունն անվճար է: հեռախոսահամարով: թարգմանիչ խնդրելու համար պարզապես զանգահարեք 1-866-880-0606 Հայերեն խոսացող որևէ անձ կօգնի ձեզ:Այս ծառայությունն անվճար է: Cambodian: Cambodian: យើ ង មា ន សេ វា ប ក ប្ រែ ភា សា ដោ យ ឥ ត គិ ត ថ្ លៃ ដើ ម្ បី ឆ្ លើ យ សំ ណួ រ ផ្ សេ ង ៗ ដែ ល លោ ក អ្ ន ក ប្ រ ហែ ល មា ន អំពីផែនការសុខភាព ឬឳសថរបស់យ ើង។ ដើម្បីទទួលបានអ្នកបកប្រែភាសា ម្នាក់ សូមទូរស័ព្ទមកយើងតាមលេខ 1-866-880-0606។ មានបុគ្គលិកន ិយាយភាសាអង់គ ្លេសណាម្នាក់អាចជួយអ ្នកបាន។1-866-880-0606 នេះជាសេវាដោយឥតគិត ថ្លៃ។ Farsi: Farsi: ییوگخساپترجمه خدمات،باشید داروی ما بهداشت برنامه درباره تشادهب است سواالتیو که ممکن پاسخگویی برای یارب داشتههب یتالاوس نکممو هک تسا هرابرد همانرب هتشادبهام یوراد دیشاب، شماره است با یهافشکافی ،شفاهی رایتخا باردمترجم برقراری ارتباط یمبرای .دهیم یاربمی شما قرار طابترااختیار شفاهیابرایگان در تامدخ همجرت ناگیار رارق امش میهد. یرارقرب مجرتم .است رایگان خدمات این .کرد هد خوا کمک شما به زبان انگلیسی نفر یک .بگیرید تماس 1 800 886 6060 یهافش، هرامش اب تسا یفاک0606-880-866-1 دیریگب سامت. نابز یسیلگنا رفن کی هب درک دهاوخ کمک امش. تسا ناگیار تامدخ نیا. Hmong: Hmong: Peb Peb muaj muaj neeg neeg txhais txhais lus lus dawb dawb los los teb teb txhua txhua los los lus lus nug nug uas uas koj koj muaj muaj rau rau ntawm ntawm peb txoj kev npaj kho mob mob nkeeg nkeeg lossis lossis txoj txoj kev kev npaj npaj muab muab tshuaj tshuaj khomob. khomob. Xav tau ib tus neeg txhais lus, hau rau peb ntawm 1-866-880-0606. neeg uas uaspaub paubhais haislus lusAskiv Askivyuav yuav pab Qhov ib qho 1-866-880-0606. Ib tus neeg pab tautau koj.koj. Qhov no no yogyog ib qho kev kev pab pab dawbdawb pub pub pej xeem. rau rau pej xeem. H7885_MMP_15150_001_14_EN Approved
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