Aetna Assure Premier Plus Enrollment Request Form
This document provides essential instructions for enrolling in Aetna Assure Premier Plus (HMO D-SNP) for 2023. It is important for individuals eligible for Medicare who wish to join the plan. Follow the guidelines to complete your enrollment successfully.
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How do I fill this out?
To fill out this form, gather your Medicare Number and other relevant information. Ensure that you provide accurate details to avoid delays. Follow the instructions carefully to complete your application.
How to fill out the Aetna Assure Premier Plus Enrollment Request Form?
1
Gather necessary documents including your Medicare Number.
2
Fill out the form clearly and completely.
3
Sign and date the form.
4
Make a copy for your records.
5
Submit the form by the designated method.
Who needs the Aetna Assure Premier Plus Enrollment Request Form?
1
Individuals on Medicare looking to switch to Aetna Assure Premier Plus.
2
New Medicare beneficiaries wishing to enroll in a Medicare Advantage plan.
3
Individuals with both Medicare Part A and B who reside in the service area.
4
People looking for comprehensive health coverage options.
5
Those seeking assistance with their Medicare enrollment process.
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1
Open the PDF in PrintFriendly.
2
Select the text you want to edit.
3
Make the necessary changes.
4
Review the edited content.
5
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What are the instructions for submitting this form?
To submit your Aetna Assure Premier Plus enrollment form, you can fax it to 1-844-984-0393 or mail it to Aetna Medicare, PO Box 7083, London, KY 40742. Ensure you include all necessary information and sign the document before submission. For any assistance, feel free to call Aetna Medicare at 1-833-874-8529.
What are the important dates for this form in 2024 and 2025?
The important enrollment period for 2024 is from October 15 to December 7, when you can sign up for the Aetna Assure Premier Plus plan. It is crucial to submit your application by the deadline for coverage starting January 1. For 2025, be mindful of similar enrollment dates.
What is the purpose of this form?
The purpose of this form is to facilitate the enrollment of eligible individuals into the Aetna Assure Premier Plus (HMO D-SNP) plan for 2023. Completing this form ensures that you receive all the necessary healthcare benefits under this medical plan. It is designed to provide a clear and structured way to gather essential information for your enrollment.
Tell me about this form and its components and fields line-by-line.
- 1. Medicare Number: Your unique Medicare identifier.
- 2. Permanent Address: Your current residential address.
- 3. Phone Number: A contact number where you can be reached.
- 4. Health Insurance Information: Details of any other insurance you hold.
What happens if I fail to submit this form?
Failure to submit this form may result in not receiving your desired coverage under the Aetna Assure Premier Plus plan. It is essential to provide all necessary information accurately to avoid issues in processing your application.
- Delay in Coverage: Without timely submission, your coverage may start later than intended.
- Loss of Enrollment Opportunity: Missing the deadline can mean waiting another year to enroll.
How do I know when to use this form?
- 1. Annual Enrollment Period: Use this form between October 15 and December 7 each year.
- 2. New Medicare Beneficiary: Enroll within three months of receiving Medicare eligibility.
- 3. Special Enrollment Situations: Situations such as losing other coverage may allow for enrollment at different times.
Frequently Asked Questions
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Is there assistance for filling out the form?
Yes, you can find assistance via the contact numbers provided in the form.
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When is the deadline to submit my form?
The completed form must be submitted by December 7 for enrollment starting January 1.
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How can I confirm my form was received?
Ensure you keep a copy of the submitted form and consider sending it via certified mail for confirmation.
What information do I need to complete the form?
You will need your Medicare Number, personal address, and any other health insurance information.
