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.

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 711) to see if you are eligible to enroll. Our office hours are Monday through Sunday 8am - 8pm.

Special Instructions For Beneficiaries

Please fill out the entire form accurately. Your Medicare information must be filled out exactly as it appears on your Medicare card.
Be sure to read each item carefully so that you fully understand the information.
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.
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.

*Thank you for your interest in Physicians United Plan (PUP). In order to enroll in PUP Extra HMO, you must have Medicare and Medicaid at the time of enrollment. You can submit your application along with your Medicaid proof in two easy ways:

By Mail:
9102 Southpark Center Loop
Suite 200
Orlando, FL 32819
By Fax:
407-226-1921

You can also call us to speak with one of PUP’s Customer Service Representatives at 866-571-0693 (TTY users should call 711 or 711) to see if you are eligible to enroll. We are open Monday through Sunday from 8 am until 8 pm.

Paying Your Plan Premium

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay PUP the Part D-IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or:

Call Social Security at 1-800-772-1213.
TTY users should call 1-800-325-0778
You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

If you don’t select a payment option, you will get a bill each month.

Please select a premium payment option:* Get a bill Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. (The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

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Required information is marked with*

Part 2 of 5: Your Medicare Information

Please take out your Medicare card to complete this section.

Please fill in the blanks so they match your red, white and blue Medicare card.

You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

First Name*

Middle Name

Last Name*

Medicare Claim Number*

Sex*

Is entitled toEffective Date

Hospital (Part A)*

Medical (Part B)*

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Required information is marked with*

Part 3 of 5: Your Personal Contact Information

Applicant Information

Birth Date*

Sex*

Home Phone Number*

Alternate Phone Number

Permanent Residence

Street Address (P.O. Box is not allowed)*

Apt. or Ste.

City*

State

Zip*

County*

I have a different Mailing Address

Mailing Address

Street Address*

Apt. or Ste.

City*

State*

Zip*

Email Information

Email Address

By checking this box, I request that PUP send me important plan materials and special news and updates via email when this service is available. I understand that I may choose to opt out of this service at any time by contacting PUP's Member Services Department.

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Required information is marked with*

Part 5 of 5: Agree and Submit

Alternative Language or Format Preference

Please check this box if you would prefer us to send you information in Spanish.

Please contact PUP at 1-866-571-0693 (TTY users should call 711) if you need information in another format (like Braille, audio tape, or large print) or language than what is listed above. Our oce hours are Monday through Sunday 8am - 8pm.

STOP! Please read this important information

If you currently have health coverage from an employer or union, joining PUP could affect your employer or union health benefits. You could lose your employer or union health coverage if you join PUP. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

Release of Information:

By joining this Medicare health plan, I acknowledge that PUP will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that PUP will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. 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 will 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 Individual Enrollment Request Form means that I have read, understand and agree to the contents of this form and the Statements of Understanding and General Membership Rules on the back of this form. 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.

Your Initials*

If you are the authorized representative of the applicant, you must sign above and provide the following information:

Name

Relationship to Applicant

Address

Phone Number

Submit My Application Go back

Attestation of Eligibility for an Enrollment Period

Special Instructions For Beneficiaries

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

Statements of understanding and general membership rules

By Mail:

By Fax:

STOP! Please read this important information

Release of Information: