Optional vision, dental and hearing enrollment form

Optional Enhanced Vision, Dental
and Hearing enrollment form
As a member of a Priority Health Medicare plan, you have an opportunity to add the Enhanced
Vision, Dental and Hearing package to your coverage. You’re not required to enroll in this optional
benefit. You have two months from the effective date of your Priority Health Medicare plan to elect
this package.
For PriorityMedicare ValueSM (HMO-POS), PriorityMedicare MeritSM (PPO),
PriorityMedicareSM (HMO-POS) or PriorityMedicare SelectSM (PPO):
This option is in addition to the standard dental benefits offered with your plan.
Note: You do not have to complete this form to receive the standard dental benefits that are part
of your Priority Health Medicare Advantage coverage. By completing this form you will be enrolled
in the optional enhanced vision, dental and hearing plan package 1 and agree to pay an additional
monthly premium of $19.00. Once you are enrolled, you will receive information via mail, including
certificates of coverage.
For PriorityMedicare KeySM (HMO-POS) and PriorityMedicare IdealSM (PPO):
By completing this form you will be enrolled in the optional enhanced vision, dental and hearing
package 2 and agree to pay an additional monthly premium of $29.00. Once you are enrolled, you
will receive information via mail, including certificates of coverage.
To add enhanced vision, dental and hearing there are three easy ways to enroll:
•Use our secure online form at priorityhealth.com/enhancedpackage
•Call us toll-free at 877.435.8724, from 8 a.m. – 8 p.m., seven days a week.
TTY users should call 711
•Complete and mail this form in the enclosed postage-paid reply envelope
If you do not have a postage-paid reply envelope, you can send your completed form to:
Priority Health
1231 East Beltline NE
MS 1175
Grand Rapids, MI 49525
Note: You must be a current Priority Health member to enroll. This plan will be effective on
either the same date as your MAPD or Medigap plan, or the first of the month.
To enroll, please provide the following information:
Priority Health Medicare Subscriber ID
Last name­
First name
M.I.
Birth date
____/____/_____
MM DD YYYY
Sex
M
F
Phone number that we may use to contact you:
(
)
Landline (home phone)
Cell phone
City
County
State
ZIP code
Email address
Paying your plan premium:
The way you choose to pay your Medicare Advantage premium will automatically be the same method that’s used to pay for
this enhanced dental plan.
You cannot change how you pay for your Medicare Advantage premium with this form. If you want to change how you pay for
your Medicare Advantage plan premium, call Priority Health customer service toll-free at 888.389.6648, from 8 a.m. –
8 p.m., seven days a week. TTY users should call 711.
Please read and sign below:
By completing this enrollment application, I agree to the following:
The Enhanced Vision, Dental and Hearing package is an optional benefit offered by Priority Health Medicare, which has a contract with the
federal government. I understand that in order to enroll in the Enhanced Package I must have either PriorityMedicare KeySM (HMO-POS),
PriorityMedicare IdealSM (PPO) PriorityMedicare ValueSM (HMO-POS), PriorityMedicare Merit (PPO), PriorityMedicareSM (HMO-POS),
PriorityMedicare SelectSM (PPO). I also understand my enrollment in this optional vision, dental and hearing package is voluntary and is not
required for me to keep my Priority Health Medicare plan.
Enrollment in the Enhanced Package is generally for the entire year. Once I’m enrolled I may voluntarily disenroll from this optional benefit by
giving advance notice in writing. I’ll be disenrolled effective on the first of the month after Priority Health Medicare receives my signed and
completed disenrollment request. I won’t need to pay monthly premiums for this optional benefit for any month after my disenrollment date.
If I pre-paid an entire year for this optional benefit, I’ll receive a pro-rated refund for the portion of the year after my disenrollment date.
I understand that I may be involuntarily disenrolled if I do not pay my monthly premium by the first day of the month. If we have not received
your Enhanced Package premium by the first of the month, we will send you a notice telling you that your membership in the Enhanced
Vision, Dental and Hearing Package will end if we do not receive your premium within 90 calendar days.
I understand that the enhanced vision, dental and hearing package is offered through vendors contracted with Priority Health Medicare to
offer these services. The enhanced vision benefit is offered through EyeMed. Benefits apply to services provided by an EyeMed participating
provider. If I use a non-participating provider the plan will cover the benefit at the benefit level listed on the Summary of Enhanced Vision
Benefits. The enhanced dental benefit is offered through Delta Dental. Benefits apply to services provided by a Delta Dental PPO or Premier
participating dentist. If I use a non-participating Delta Dental provider the plan will cover the benefit at the benefit level listed on the Delta
Dental Summary of Dental Benefits. The enhanced hearing benefit is underwritten by Security Life and serviced by EPIC Hearing Healthcare.
Benefits apply to services provided by EPIC Hearing Healthcare participating providers and non-EPIC Hearing Healthcare providers. If I use
a non-participating EPIC Hearing Healthcare provider the plan will cover the benefit at the benefit level listed on the Summary of Enhanced
Hearing Benefits or in your policy.
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’ll be disenrolled from the plan.
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 this person is authorized under state law to complete this enrollment.
Today’s date:
Signature ____/____/_____
MM DD YYYY
If you are the authorized representative, you must sign above and provide the following information:
Name: Address: Phone number: Relationship to enrollee: Office Use Only:
Subscriber ID: Effective date of coverage: ____/____/_____
Not eligible: Reason: Processing rep: Date processed: ____/____/_____
Priority Health has HMO-POS and PPO plans with a Medicare contract. Enrollment in Priority Health Medicare depends on
contract renewal. You must continue to pay your Medicare Part B premium. Y0056_1000_1097_29_CMS-approved 08112015
©2015 Priority Health MR288 9006D 10/15