MediSun Health Plan CareOptions Election Form

Completing the Application Process

• Please complete the application using black ballpoint pen, and press firmly. There are detailed instructions on the back of the page. Please read the instructions and statements carefully. If you have any questions, please call MediSun Health Plan at the telephone numbers listed on the back of this cover page.
  
  
• Please make a photocopy of your Medicare Health Insurance card and include it with the election form.
  
  
• Sign and date the election form upon completion. If you are the applicant's representative, you must have a Durable General Power of Attorney or court-ordered Legal Guardianship to sign on his / her behalf. Please provide a copy of the paperwork with the application.
  
  
• Return the completed forms and a copy of your Medicare card in the envelope included with your packet of information. Retain the pink copy of your election form for your records. In most cases, we will acknowledge the receipt of your application in writing before the effective date.

It's as simple as that to enroll in MediSun Health Plan CareOptions!

Thank you for choosing MediSun Health Plan

H5908001-103-6 11/17/2005

Pre-Enrollment Materials

MediSun Health Plan encourages you to let us know right away if you have questions, concerns, or complaints related to MediSun Health Plan, a medical service, or the care you receive from our providers.

At the time of enrollment, a Personal Assistant Liaison (PAL) is assigned as your key contact when you have questions, concerns or complaints. Please call you PAL for assistance right away if you have a question or concern either using their personal telephone number or the general Member Services telephone number, 623-974-7430, option 1 or TTY 623-074-7440. They will be happy to answer your questions and assist you with concerns.

As a plan member, Federal law guarantees your right to make complaints. The medicare program has helped set the rules about what you need to do to make a complaint and what we are required to do when we receive a complaint. When you make a complaint, we must be fair in how we handle the complaint. You cannot be disenrolled or penalized in any way if you make a complaint.

When you enroll in MediSun Health Plan and annually thereafter, you will receive an Evidence of Coverage. This is our guide to everything about MediSun Health Plan. Please keep your Evidence of Coverage handy and refer to it when you have questions about your benefits, the plan rules, the process for making complaints, and other health plan related functions. Your PAL is available by telephone to personally assist you, Monday through Friday 8:00am to 5:00pm. Information about MediSun Health Plan and our contract with the Centers for Medicare & Medicaid Services

MediSun Health Plan has an annual contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare. At the end of each year, the contract is reviewed, and either MediSun Health Plan or CMS can decide not to renew. CMS also allows MediSun Health Plan to expand or reduce the size of our service area, the area in which you must live to be a member of MediSun Health Plan. If MediSun Health Plan’s contract is not renewed or the service area is reduced so that it no longer includes the area where you live, your membership with MediSun Health Plan will end. Important Information in Completing this Election Form

1. NAME Please print your name exactly as it is written on your Medicare Health Insurance Card, even if there is an error. Errors need to be corrected with your local Social Security Administration Office. We will be notified of your corrected name by the Centers for Medicare and Medicaid Services (CMS).


2. PROPOSED EFFECTIVE DATE >Your actual effective date will be determined by MediSun Health PlanONE based upon the receipt of your completed election form and confirmation of that date by CMS. This effective date is always on the first day of the month.


3. ALTERNATIVE CONTACT - Provide the name of a friend or relative, who does not reside with you, for an alternative contact should we be unable to reach you.


4. MEDICARE CLAIM NUMBER - Please print your Medicare Claim Number exactly as it is written on your Medicare Health Insurance Card. You must be entitled to Medicare Part A and enrolled in Medicare Part B to enroll in MediSun Health Plan CareOptions. Please complete the effective dates of your Part A and B coverage on the form.


5. STATEMENTS OF UNDERSTANDING - Read each statement carefully. If there is anything you do not understand, please do not hesitate to contact MediSun Health Plan at (623) 974-7430, or 1-800446-8331 if you are outside Maricopa County. If you have a hearing impairment and have a telecommunications device for the deaf, call our TTY line at (623) 974-7440. Our business hours are Monday through Friday, 8:00 a.m. to 5:00 p.m.


6. SIGNATURE - Read the Statements of Understanding. By signing your election form, you agree to follow the plan rules and have an understanding of your member responsibilities. If you have any questions, please call us. Sign your name as it is listed on your Medicare Health Insurance Card, and date the form. Keep the pink copy of the election form for your records. In most cases, we will acknowledge the receipt of your application in writing before the effective date. (If you are assisting the Medicare beneficiary in completing this form, please contact MediSun Health Plan at the above telephone numbers for further instructions.)

MediSun Health Plan
PO Box 1489
Sun City, AZ 85372-1489