Nascentia Health Plus Medicare Advantage Enrollment Request Form (Virtual)

The following Enrollment Form is to complete a virtual enrollment in a Medicare Advantage Plan (Part C) with Medicare Prescription Drug Plan (Part D)

MA HMO Enrollment Application - Virtual Part 1 (new)
  • Enrollment Section 1
  • Enrollment Section 2
  • Enrollment Section 2 continued
  • Agent Checklist
    • Summary

    Enrollment Request Form

    Section 1—All fields on this page are required (unless marked optional)

    Select the plan you want to join:
    Sex:
    Include area code
    Mailing address, if different from you permanent address (P.O. Box allowed):
    Will you have other prescription drug coverage (like VA, TRICARE) in addition to Nascentia Health Plus?
    Are you enrolled in your state Medicaid program?
    IMPORTANT: Read and sign below

    • I must keep both Hospital (Part A) and Medical (Part B) to stay in Nascentia Health Plus.
    • By joining this Medicare Advantage Plan, I acknowledge that Nascentia Health Plus 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 on the next page).
    • 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 Nascentia Health Plus coverage begins, I must get all my medical and prescription drug benefits from Nascentia Health Plus. Benefits and services provided by Nascentia Health Plus and contained in my Nascentia Health Plus “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Nascentia Health Plus 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. If signed by an authorized representative (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 Medicare
    If you're the authorized representative, sign above and fill out these fields.

    Last Updated on December 20, 2023