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Prior to beginning your online enrollment, please be sure that you have all of the
information needed to complete the form. By filling out and submitting this information,
you are sending an actual enrollment request to Inter Valley Health Plan.
• Your Medicare ID Card
If you do not have your card, you will need:
• Your Medicare Number
• Part A Effective Date
• Part B Effective Date
• Please write your last
name, first name, and
middle initial exactly
as it appears on your
Medicare card. Your
Inter Valley Health Plan
membership card will
reflect your name as it
appears on your Medicare
card.
• Your Medi-Cal ID Card (if applicable)
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• Your Chosen Primary Care Physician
Information
• including affiliated Medical Group
• Your emergency contact information
• If you have other prescription drug coverage,
you will need:
• Name of Coverage
• ID Number
• Group Number
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Your enrollment effective date is subject to approval by the Centers for Medicare
+ Medicaid Services (CMS). Upon confirmation from CMS, Inter Valley Health Plan
will mail you written notice of your enrollment effective date.
You may pay a financial penalty if you did not enroll in a plan offering Medicare
Part D drug coverage when you first became eligible for this drug coverage or you
experienced a continuous period of 63 days or more when you didn’t keep your prescription
drug coverage. The amount of the penalty depends on how long you waited before you
enrolled in drug coverage after you became eligible or how many months after 63
days you went without drug coverage.
Your late enrollment penalty is considered to be part of your plan premium.
For information on completing this enrollment form, please call our Sales Department
at (800) 500-7018 or for the hearing impaired, TTY/TDD users (800) 505-7150. Alternate
formats are available and can be requested by calling the number above. We are open
from 7:30AM - 8:00PM, seven days a week.
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| © 2011 Copyright Inter Valley Health Plan. All Rights Reserved. |
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