AUTHORIZATION & DISCLOSURE INFORMATION

If you currently have health coverage from an employer or union, joining Senior Care Plus could affect your employer or union health benefits. If you have health coverage from an employer or union, joining Senior Care Plus may change how your current coverage works. Read the communications that your employer or union sends to you. If you have questions, visit their Website, or contact the office listed in their communications. If there is no information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help. Talk to them about a Creditable Coverage Letter.

I UNDERSTAND that if I sign up for Medicare prescription-drug coverage from any Medicare drug plan other than Senior Care Plus, I will be disenrolled automatically from Senior Care Plus.  This disenrollment would affect both my current doctor and hospital coverage and my prescription-drug benefits provided by Senior Care Plus.

By completing this enrollment application, I agree to the following:

Senior Care Plus is a Medicare Advantage Plan, and I will need to keep my Parts A and B. I can only be in one Medicare Advantage Plan at a time. It is my responsibility to inform you of any prescription-drug coverage that I have or may get in the future. Having other prescription-drug coverage may effect my enrollment with Senior Care Plus. Enrollment in this plan is generally for the entire year. I may leave this plan only at certain times of the year, or under certain special circumstances, by sending a request to Senior Care Plus or by calling 1-800-Medicare. TTY users should call 1-877-486-2048.

Senior Care Plus serves a specific service area (Washoe County). If I move out of the area that Senior Care Plus serves, I need to notify the plan so I can disenroll and find a new plan in my area. Once I am a member of Senior Care Plus, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage (EOC) document from Senior Care Plus when I receive it to know the rules that I must follow to receive coverage with this Medicare Advantage Plan.

I UNDERSTAND that Medicare beneficiaries generally are not covered under Medicare while out of the country except for limited coverage in Canada and Mexico. Senior Care Plus provides world-wide coverage for emergency services and out-of-area dialysis services.

RELEASE OF INFORMATION: 

By joining Senior Care Plus, I acknowledge that the Medicare Advantage Plan will release my information to Medicare and other plans as is necessary for treatment, payment and healthcare operations. 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 Senior Care Plus.

I UNDERSTAND that Hometown Health Plan may disclose, to the extent permitted by law, my personal information within Washoe Medical Center’s family of companies. Hometown Health Plan may disclose transaction and experience information to affiliated third parties and/or other entities within Washoe Medical Center only to the extent that it is required for treatment, payment, or healthcare operations or that is permitted by law (such as for compliance with a subpoena, fraud prevention or inquiries from state or federal agencies).

I UNDERSTAND that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the state where the individual resides) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 Senior Care Plus or by Medicare.