Attestation of Eligibility for an Enrollment Period

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15th through December 7th of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

	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 moved on (insert date & city you moved to and from ).
	I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on (insert date) .
	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 stopped receiving extra help on (insert date) .
	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 moved/will move into/out of the facility on (insert date & name of the facility) .
	I recently left a PACE program on (insert date) .
	I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug coverage on (insert date & name of coverage) .
	I am leaving employer or union coverage on (insert date & name of 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. I was disenrolled from the SNP on (insert date)

If none of these statements applies to you or you’re not sure, please contact PUP at 1-866-571-0693 (TTY users should call 1-800-955-8771) to see if you are eligible to enroll. Our office hours are Monday through Sunday 8am - 8pm.

Special Instructions For Beneficiaries

1. Please fill out the entire form accurately. Your Medicare information must be filled out exactly as it appears on your Medicare card.
2. Be sure to read each item carefully so that you fully understand the information.
3. When completing this online form, please use the "Continue" or "Go back" buttons at the bottom of each screen to move between sections. Do not use your browser's forward or back buttons.
4. Once you have completed all sections and reached the end of the form, use the "Submit My Application" button to send the form to PUP. Your information will not be submitted until the entire form has been completed and you receive your confirmation message.

Important - Please read this section before signing this Individual Enrollment Request Form

Statements of understanding and general membership rules

By completing this enrollment application, I agree to the following:

• Physicians United Plan (PUP) is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B.
• I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future.
• Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15 – December 7 of every year), or under certain special circumstances.
• PUP serves a specific service area. If I move out of the area that PUP serves, I need to notify the plan so I can disenroll and nd a new plan in my new area.
• Once I am a member of PUP, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from PUP when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan.
• I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.
• I understand that beginning on the date PUP coverage begins, I must get all of my health care from PUP, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by PUP and other services contained in my PUP Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR PUP WILL PAY FOR THE SERVICES.
• I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with PUP, he/she may be paid based on my enrollment in PUP.