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Enhanced Vision, Dental and Hearing Enrollment Form


As a member of a Priority Health Medicare plan, you have an oppurtunity 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.


 

 



 

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Please enter your permanent address below. If you have more than one residence, enter your primary residence.
(Don't use a P.O. Box).

 



 

 

 

 

The way you choose to pay your Medicare Advantage premium will automatically be the same method that’s used to pay for this enhanced vision, dental and hearing plan.

You cannot change how you pay for your Medicare Advantage plan 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., 7 days a week. TTY users should call 711.

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 MeritSM (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.


 
If you are the authorized representative, you must provide the following information.











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(if assisted in enrollment)


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You will not be able to print it after you click "Enroll."