Office Use Only: Date Stamp

Amerivantage (HMO)

Medicare Advantage Plan Individual Short Enrollment Request Form for 2017 Please read the following:

Use this form only if you are changing Amerivantage (HMO) plans - not to enroll the first time.Be sure to complete all appropriate sections of thisform and sign where indicated. Mail the completed form, including this cover page, to the address below:

AmerigroupP.O. Box 659403San Antonio, TX 78265-9714

Or fax the completed form to: 1-800-833-8554

AMERIGROUP Texas, Inc. is an HMO plan with a Medicare contract. Enrollment in AMERIGROUP Texas, Inc. depends on contract renewal.

H5817_020-001, 023Y0114_17_27721_R 203 CMS approved 09/15/2016 TX

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Individual Short Enrollment Request Form for 2017 Section 1: Provide the following information: (Please print clearly.)Please check which plan you want to enroll in.

Amerivantage Classic (HMO)$0.00

Amerivantage Select (HMO)$0.00

Last name First name MI Birth date (mm/dd/yyyy)

Member ID number Email address (optional)

Phone number – –

Alternate phone number – –

County

Permanent residence street address (P.O. Box is not allowed.) City State ZIP code

Mailing/billing address (only if different from your permanent address) City State ZIP code

Section 1A: Please fill out the following: I am currently a member of the__________________________________ plan with a monthly premium of $__________________. I would like to change to the__________________________ plan. I understand that this plan has different health benefits and a monthly premium of $_________________. Section 1B: If you are changing to a different primary care physician (PCP), please choose a new PCP from the plan’s Provider Directory. Then complete the information below. Provider’s name

Provider’s street address

City State ZIP code

PCP ID # (See directory.) ___________________

New physician for you? Yes No

If enrolling in an Independent Practice Association (IPA) or a Participating Medical Group (PMG) instead of a PCP, provide code here ___ ___ ___ .

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Member Name _________________________________ & Member ID #___________________________

Section 2: Please complete this section only if you are changing your current paymentmethod or choosing a payment option for the first time.

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail or electronic funds transfer (EFT) (automatic bank account deduction) each month or quarterly. You can also pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D Income-Related Monthly Adjustment Amount (IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. Do NOT pay Amerivantage (HMO) the Part D IRMAA.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify won’t have acoverage gap or a late enrollment penalty. Many people qualify for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.

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Member Name _________________________________ & Member ID #___________________________

If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount Medicare doesn’t cover. If you don’t select a premium payment option below, you will get a bill each month. Please select a premium payment option:

Monthly bill: Send me a bill each month. Automatic bank account deduction: Electronic funds transfer (EFT) from my bank account each

month. (Depending on when you apply, more than one month’s amount might be deducted for your first payment.) Please complete steps 1, 2 and 3 below: 1) Account type: Checking: (must include a voided check):

Savings: Must enclose a notice from financial institution showing accountinformation and bank routing numbers.

2) Please complete the following information for your account: Account holder name________________________ Account number________________________ Bank routing number(This is the first 9 digits printed on the lower left corner of your check.)

________________________ Bank name_____________________________

3) I authorize the bank above to allow this monthly deduction of the amount from the account above. Automatic Social Security or Railroad Retirement Board (RRB) Deduction: Deduct the amount

from my Social Security or Railroad Retirement Board (RRB) benefit check each month. (After Social Security or RRB approves the automatic deduction, it may take two or more months for the deduction to begin. In most cases, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the date the automatic deduction begins. If Social Security or RRB delays or does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

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Member Name _________________________________ & Member ID #___________________________

Section 3: Please read and sign at the end of this section. Amerivantage (HMO) is a Medicare Advantage plan and has a contract with the federal government. 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 automatically will 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. I understand that if I don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. I will read the Evidence of Coverage document from Amerigroup when I get it to know what I must follow to maintain coverage. I understand that if I have had a prior break in creditable prescription drug coverage (as good as Medicare’s), or leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription coverage (as good as Medicare’s), I may have to pay a late enrollment penalty in addition to my premium for Medicare prescription drug coverage. Enrollment in this plan is generally 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 (for example, October 15 – December 7 of every year), or under certain special circumstances. I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with Amerivantage (HMO), he/she may be compensated based on my enrollment in Amerivantage (HMO).

Release of Information: By joining this Medicare health plan, I acknowledge that Amerigroup will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations.

I also acknowledge that Amerivantage (HMO) will release my information, including my prescription drug event data, to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. 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 Medicare beneficiaries aren’t covered under Medicare while out of the country, except for limited coverage near the U.S. border. I understand that beginning on the date Amerivantage (HMO) coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, Amerigroup provides refunds for all covered benefits, even if I get services out-of-network. Services authorized by Amerigroup and other services contained in my Amerivantage (HMO) Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR AMERIGROUP WILL PAY FOR THE SERVICES.

I understand that my signature (or the signature of the person authorized to act on my behalf under the laws of the state where I live) 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 thisauthority is available upon request from Medicare.

Signature required to process. Applicant Signature or Authorized Representative as described above*

Today’s date

Desired plan effective date

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Member Name _________________________________ & & Member ID #___________________________

*Authorized Representative Information Only All fields within this section must be completed if the application has been signed by an Authorized Representative and not the Applicant. Name____________________________________________________________________________ Address__________________________________________________________________________ Phone number ________-_________-__________ Relationship to enrollee _____________________________________________________________ _____________________________________________________________ Please contact Amerigroup at 1-866-805-4589 if you need information in an alternate language or format. Our office hours are 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christ-mas) from October 1 through February 14, and Monday to Friday (except holidays) from Febru-ary 15 through September 30. TTY users should call 711. Phone help is available for most lan-guages and for reading assistance. This plan also provides some documents in these languages and formats:Spanish, Large Print, Braille, Audio Tape, Voice-Enabled PDFs.

Applicant: Please do not complete the following sections. Agent/Broker: Please complete the following section carefully. Coverage effective date______________

AEP SEP (type) ________________________________ Direct Sales Reps Only: Complete if you assisted in enrollment. Print name __________________________________________________________ Tax identification number (10 digits) or agent code (variable) __ __ __ __ __ __ __ __ __ __ Signature ___________________________________ Company received date stamp _____________ Current Agents/Brokers Only: Complete all fields. Date received from member ________________ I helped the member fill out this form Yes No Please check the ID number to use for commission payment:

Agent/Broker’s tax ID number __ __ __ __ __ __ __ __ __ __ Code number ____________ Agency tax ID number __ __ __ __ __ __ __ __ __ __ Code number ____________

Please complete all lines below. Agent/Broker’s Printed name ______________________________ Agency name _____________________________ Address ____________________________________________________________________________ Phone number _______-_________ -_________ Fax number_______-_________ -_________ Email address ________________________________________________ Agent/Broker’s signature ________________________________________

Premiums may change on January 1 of each year.

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Please print: Member Name _________________________________ & Member ID #_____________________

Attention: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-866-805-4589 (TTY: 711)ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-805-4589 (TTY: 711).

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Please print: Member Name _________________________________ & Member ID #_______________________