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Please Read and sign Below Medicare HMO Blue ValueRx (HMO)

By completing this enrollment application, I agree to the following: Medicare HMO Blue FlexRx (HMO-POs) 2017
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Medicare HMO Blue ValueRx/ FlexRx/PlusRx is a Medicare Advantage plan and has a contract with the federal government. Medicare HMO Blue PlusRx (HMO)
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I will need to keep my Medicare Parts A and B. 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. It is my
responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally To Complete Your Enrollment Form:
for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period
is available (Example: October 15–December 7 of every year), or under certain special circumstances. Be sure to complete all information, sign, and date your enrollment form. Please keep a copy of the enrollment form for your records.
Return the completed form(s) in the enclosed envelope. If you lose the return envelope, mail your application to: Blue Cross
Medicare HMO Blue ValueRx/ FlexRx/PlusRx serves a specific service area. If I move out of the area that Medicare HMO Blue ValueRx/
FlexRx/PlusRx serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Blue Shield of Massachusetts, Enrollment Department, P.O. Box 55011, Boston, MA 02205. We will contact you in writing
Medicare HMO Blue ValueRx/FlexRx/PlusRx, I have the right to appeal plan decisions about payment or services if I disagree. I will read when we receive your enrollment form, and then again to notify you of your effective date.
the Evidence of Coverage document from Medicare HMO Blue ValueRx/ FlexRx/PlusRx when I get it to know which rules I must follow
to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare To Enroll in Medicare HMO Blue ValueRx, Please check which plan you want to enroll in:
while out of the country except for limited coverage near the U.S. border. Medicare HMO Blue FlexRx, or Medicare HMO Blue ValueRx | $39 per month
I understand that beginning on the date Medicare HMO Blue ValueRx/FlexRx/PlusRx coverage begins, I must get all of my health care Medicare HMO Blue PlusRx, Medicare HMO Blue FlexRx | $99 per month
from Medicare HMO Blue ValueRx/FlexRx/PlusRx, except for emergency or urgently needed services or out-of-area dialysis services. Please Provide the Following Information: Medicare HMO Blue PlusRx | $295 per month
Services authorized by Medicare HMO Blue ValueRx/FlexRx/PlusRx and other services contained in my Medicare HMO Blue ValueRx/ Last Name First Name Middle Initial Mr. Mrs. Ms.
FlexRx/PlusRx Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without
authorization, NEITHER MEDICARE NOR MEDICARE HMO BLUE VALUERX/FLEXRX/PLUSRX WILL PAY FOR THE SERVICES.
Birth Date (MM/DD/YYYY) Sex Email Address Home Phone Number
I understand that if I am getting assistance from a sales agent, broker, or other individual I understand that my signature (or the / / M F ( ) –
employed by or contracted with Medicare HMO Blue ValueRx/FlexRx/PlusRx, he/she may signature of the person authorized to act
be paid based on my enrollment in Medicare HMO Blue ValueRx/FlexRx/PlusRx. on my behalf under the laws of the state Permanent Residence Street Address (P.O. Box is not allowed) Alternate Phone Number
where I live) on this application means that Number and Street ( ) –
Release of Information: By joining this Medicare health plan, I acknowledge that
Medicare HMO Blue ValueRx/FlexRx/PlusRx will release my information to Medicare I have read and understand the contents of City State Zip Code
and other plans as is necessary for treatment, payment, and health care operations. this application. If signed by an authorized
I also acknowledge that Medicare HMO Blue ValueRx/FlexRx/PlusRx will release my individual (as described above), this Mailing Address (only if different from your Permanent Residence Address)
information, including my prescription drug event data to Medicare, who may release signature certifies that:
it for research and other purposes which follow all applicable Federal statutes and 1) this person is authorized under state law Number and Street
regulations. The information on this enrollment form is correct to the best of my to complete this enrollment and City State Zip Code
knowledge. I understand that if I intentionally provide false information on this form, 2) documentation of this authority is
I will be disenrolled from the plan.
available upon request from Medicare. Emergency Contact Name Phone Number Relationship to You
Your Signature Today’s Date
Please Provide Your Medicare Insurance Information
If you are the authorized representative, you must sign above and provide the following information: Please provide your Medicare insurance information.

Name Phone Number
Please fill in these
( ) – Attach a copy of your
blanks so they OR Name:
Address Relationship to Enrollee match your red, Medicare card or your letter Medicare Claim Number Sex
from Social Security or the
white, and blue Railroad Retirement Board.
Medicare card. - -
Is Entitled To Effective Date
You must have Medicare Part A and Part B to join
Blue Cross Blue Shield of Massachusetts is an HMO and PPO plan with a Medicare contract. Enrollment in Blue Cross Blue Shield a Medicare Advantage plan. HOSPITAL (Part A) ______________________
of Massachusetts depends on contract renewal. Blue Cross Blue Shield of Massachusetts complies with applicable federal civil rights MEDICAL (Part B) ______________________
laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation or gender identity. Plan ID# ICEP/IEP AEP
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-200-4255 (TTY: 711). Office Use Only
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-200-4255 (TTY: 711). Name of Staff Member/Agent
Effective Date of Coverage SEP (type) Not Eligible
®, SM Registered and Service Marks of the Blue Cross and Blue Shield Association. © 2016 Blue Cross (if assisted in enrollment)
and Blue Shield of Massachusetts, Inc., and Blue Cross and Blue Shield of Massachusetts HMO Blue, Inc. Blue Cross Blue Shield of Massachusetts is an Independent
167081M 55-0169-17 V2 (11/16) Licensee of the Blue Cross and Blue Shield Association H2261_16216 Approved 11142016

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