Enrollment Form
2018

Need Help?

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AlamanceGuilfordRandolphRockingham

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9% Complete





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YesNo

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18% Complete





I am new to Medicare.
I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me.
I recently was released from incarceration.
I recently returned to the United States after living permanently outside of the U.S.
I recently obtained lawful presence status in the United States.
I have both Medicare and Medicaid or my state helps pay for my Medicare premiums.
I get extra help paying for Medicare prescription drug coverage.
I no longer qualify for extra help paying for my Medicare prescription drugs.
I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility).
I left a PACE program.
I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare).
I am leaving employer or union coverage.
I belong to a pharmacy assistance program provided by my state.
My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.
I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan.





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Please contact HealthTeam Advantage if you need information in another language or format (Braille).


HealthTeam Advantage Health Plan I PPO $$0 per month
HealthTeam Advantage Health Plan II PPO $57 per month

HealthTeam Advantage Dental Rider $25 per month
HealthTeam Advantage Combo Rider $40 per month


MF

Mr.Mrs.Ms.


YesNo

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36% Complete


  • HealthTeam Advantage Health Plan
  • HealthTeam Advantage Dental Rider

  • Continue your application by clicking the "Next" button below
  • Change your selections by clicking the "Previous" button below

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YesNo

YesNo

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YesNo

YesNo


SpanishOther - specify

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6. 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 this authority is available upon request from Medicare.

I am the representative authorized to complete this application


ICEP/IEPAEPSEP (type)Not Eligible

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Have a question? We can help!

By Phone:

1-877-905-9216 (TTY 711), 8 am to 8 pm, seven days a week (EST).

By Email:

info@healthteamadvantage.com 

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