Enrollment Application 2019

Instructions and Disclaimers

Plan Recap

Here is how you can enroll in a Preferred Care Partners plan NOW:

1. Download, print and complete form with signature:

• Preferred Choice Dade (HMO) Enrollment Application
• Preferred Choice Broward (HMO) Enrollment Application
• Preferred Choice Palm Beach (HMO) Enrollment Application
• Preferred Complete Care (HMO) Enrollment Application

Application Instructions for plans above

• Preferred Special Care Miami-Dade (HMO SNP) Enrollment Application

Application Instructions

If you are enrolling in Preferred Special Care Miami-Dade (HMO SNP), you must fill out the Chronic Condition Pre-Assessment Form.

Click here to download.

• Preferred Medicare Assist (HMO SNP) Enrollment Application
• Preferred Medicare Assist Palm Beach (HMO SNP) Enrollment Application

Application Instructions

Please mail or fax to:

United Healthcare Medicare Enrollment
Attn: Xerox/ACS
3315 Central Ave.
Hot Springs, AR, 71913

Fax: 1-501-262-7070

2. OR- Complete and submit your Enrollment Form via the Medicare website

By completing and sending the enrollment election form to be enrolled, you are sending an actual enrollment election to Preferred Care Partners.

You must complete and sign an enrollment election form. Except for forms that are faxed to our plan, you should submit original, not photocopied forms.

Once we receive your enrollment election form, and prior to submitting the enrollment transaction to CMS, we will contact you (via phone or mail) to confirm that you still intend to enroll in the plan.

If your enrollment election form is incomplete, we may need to contact you to acquire additional information to complete your election.

After submitting the enrollment transaction to CMS, we may send you an acknowledgement letter notifying you that we have submitted the transaction to CMS for processing.

After we receive confirmation from CMS' systems of the enrollment transaction, we will send you one of the following letters:

• Confirmation letter notifying that you are enrolled in the plan.
• Denial of enrollment letter.
• Rejection of enrollment letter.

Election Periods and Conditions for Enrollment

Below are the periods and conditions when a Medicare eligible individual may apply for enrollment in one of our plans.

• Annual Election Period (AEP)- from October 15 through December 7
• Initial Coverage Election Period (ICEP) is for all newly-eligible Medicare beneficiaries. This period starts three months immediately before the individual's entitlement to Medicare Part A and enrollment in Medicare Part B

Medicare Website

Medicare beneficiaries may enroll in Preferred Care Partners through the CMS Medicare Online Enrollment Center, located at www.medicare.gov.

NOTE: Medicare beneficiaries with special exceptions, such as those who have Medicaid coverage or chronic conditions, can enroll at any time during the year. Contact us for additional information.

Need Assistance Completing This Form?

	Preferred Choice Dade (HMO) Preferred Choice Broward (HMO) Preferred Choice Palm Beach (HMO) Preferred Complete Care (HMO) 1-844-723-6470 (TTY 711) toll free Preferred Medicare Assist (HMO SNP) Preferred Medicare Assist Palm Beach (HMO SNP) 1-855-874-6282 (TTY 711) toll free Preferred Special Care Miami-Dade (HMO SNP) 1-855-548-1564 (TTY 711) toll free
	Open  8 a.m. to 8 p.m.    7 days a week, including holidays
	1-888-950-1170

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