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HomeMy WebLinkAboutNavitus Election Form Fillable.pdf1 Navitus (PDP)® for PRISM Medicare Prescription Plan Benefit Election Form Effective Date: ____________________________ MEMBER ENROLLMENT OR CHANGE – COMPLETE IN FULL Name (Last, First, MI): Social Security #: Birth Date (mm/ dd/yy): Male Female Home Street Address: (No P.O. Box) City, State, Zip Home Phone: Work Phone: Mailing Address: (P.O. Box may be used) City, State, Zip Same as Home Address E-mail Address: Occupation/Title: Date of Hire: (mm/dd/yy): Employee Status: Medicare Retiree Marital Status: Single Married Domestic Partner Legally Separated Divorced MEDICARE SECTION Are you retired? Yes No If yes for Medicare for you and/or your dependent(s), please provide your and/or their HICN/MBI number and indicate the entitlement reason and Medicare eligibility date for yourself and your dependents. HICN/MBI Number: _______________________________ Entitlement Reason Over 65 Disabled ESRD Effective Date of Medicare: ________________________ If yes, what Medicare are YOU enrolled in? Part A Part B Is your dependent (s) enrolled in Medicare? Yes No Name: __________________________________________ 2 If Yes for dependent, what Medicare are they enrolled in? Part A Part B HICN Number: ____________________________________ Date of Birth: _____________________________________ Gender: _________________________________________ Relationship: _____________________________________ Entitlement Reason: Over 65 Disabled ESRD Effective Date of Medicare: ________________________ Enroll In Employer Group Waiver Program (Navitus Medicare PDP) Retiree Spouse PLEASE READ THE FOLLOWING- AUTHORIZATION REQUIRED I declare that the information given on this form is true and complete to the best of my knowledge and belief. I understand that the information I have provided is the basis on which coverage may be issued under these plans. Any misstatements or omissions may result in future claims being denied and/or my coverage(s) being rescinded. I know that if I do not enroll within 30 days of becoming first eligible (or within 31 days of an IRS-qualified change in status) I will have to wait until the next annual enrollment, and may be required to submit evidence of insurability for certain coverage. Signature:Date: DECLINATION OF COVERAGE – SIGNATURE REQUIRED- Complete only if declining EGWP Rx coverage I understand that I am eligible for medical and Rx coverage through my employer. I waive the right to enroll in  the medical plan and Rx plan  as offered to me by my employer for the following reason (please check one):  I am covered under another Medicare Advantage/Supplement Plan I am covered through my spouse’s employer I have no other coverage but choose not to enroll I understand that by declining coverage,  I will not be eligible for coverage until my employer’s next Open  Enrollment period unless I qualify for coverage due to a HIPAA qualifying event (including getting married,  having a child, or involuntarily losing my other coverage). Please contact the Benefits Office at the  organization from which you retired for retiree plan provisions.   Signature:Date: