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Denver Employees Retirement Plan HMO Plan Election Form Denver Employees Retirement Plan (DERP) and Humana have joined together to offer medical and prescription coverage designed just for DERP retirees. You will notice that your enrollment packet does not include an application that needs to be completed for enrollment in the Humana Employer Medicare health maintenance organization (HMO) plan. However, for enrollment in the HMO plan, DERP requests that you complete this form and mail or return it to the DERP office. With your permission, DERP will automatically send your enrollment request to Humana for your enrollment into the HMO plan. This is an electronic enrollment process that eliminates the need for you to complete an extensive application and also prevents delays in your enrollment. If you have questions about the Humana Employer Medicare HMO plan benefits, please call Humana Group Medicare Customer Care at 1-866-396-8810. If you use a TTY, call 711. The hours of operation are Monday through Friday from 6 a.m. – 7 p.m., Mountain time. If you’re asked to leave a message, Humana will call you back by the end of the next business day. I agree to accept the Humana Employer Medicare HMO plan sponsored through Denver Employees Retirement Plan. Note: With the exception of your signature, please print or type all pertinent information below. Printed name ____________________________________________ Date __________________ Signature __________________________________________________ Medicare Identification Number ___________________________________________________ Residential Address ______________________________________________________________ Mailing Address _________________________________________________________________ Phone Number __________________________________________________________________ Primary Care Provider (PCP) Name _________________________________________________ Primary Care ID Number _________________________________________________________ If you wish to enroll in the Humana Employer Medicare HMO plan, please complete this form and return the entire form to: DERP Membership Services, 777 Pearl St., Denver, CO 80203

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Page 1: Denver Employees Retirement Plan - derp.org HMO Election Form.pdfWith your permission, DERP will automatically send your enrollment request to Humana for your enrollment into the HMO

Denver Employees Retirement Plan HMO Plan Election Form

Denver Employees Retirement Plan (DERP) and Humana have joined together to offer medical and prescription coverage designed just for DERP retirees.

You will notice that your enrollment packet does not include an application that needs to be completed for enrollment in the Humana Employer Medicare health maintenance organization (HMO) plan. However, for enrollment in the HMO plan, DERP requests that you complete this form and mail or return it to the DERP office. With your permission, DERP will automatically send your enrollment request to Humana for your enrollment into the HMO plan. This is an electronic enrollment process that eliminates the need for you to complete an extensive application and also prevents delays in your enrollment.

If you have questions about the Humana Employer Medicare HMO plan benefits, please call Humana Group Medicare Customer Care at 1-866-396-8810. If you use a TTY, call 711. The hours of operation are Monday through Friday from 6 a.m. – 7 p.m., Mountain time. If you’re asked to leave a message, Humana will call you back by the end of the next business day.

I agree to accept the Humana Employer Medicare HMO plan sponsored through Denver Employees Retirement Plan. Note: With the exception of your signature, please print or type all pertinent information below.

Printed name ____________________________________________ Date __________________

Signature __________________________________________________

Medicare Identification Number ___________________________________________________

Residential Address ______________________________________________________________

Mailing Address _________________________________________________________________

Phone Number __________________________________________________________________

Primary Care Provider (PCP) Name _________________________________________________

Primary Care ID Number _________________________________________________________

If you wish to enroll in the Humana Employer Medicare HMO plan, please complete this form and return the entire form to: DERP Membership Services, 777 Pearl St., Denver, CO 80203

Page 2: Denver Employees Retirement Plan - derp.org HMO Election Form.pdfWith your permission, DERP will automatically send your enrollment request to Humana for your enrollment into the HMO

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Important!____________________________________________ At Humana, it is important you are treated fairly. Humana Inc. and its subsidiaries do not discriminate or exclude people because of their race, color, national origin, age, disability, sex, sexual orientation, gender identity, or religion. Discrimination is against the law. Humana and its subsidiaries comply with applicable Federal Civil Rights laws. If you believe that you have been discriminated against by Humana or its subsidiaries, there are ways to get help. • You may file a complaint, also known as a grievance:

Discrimination Grievances, P.O. Box 14618, Lexington, KY 40512-4618.If you need help filing a grievance, call 1-866-396-8810 or if you use a TTY , call 711 .

• You can also file a civil rights complaint with the U.S. Department of Health and Human Services , Officefor Civil Rights electronically through the Office for Civil Rights Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf , or by mail or phone at U.S. Department of Health andHuman Services , 200 Independence Avenue, SW, Room 509F, HHH Building, Washington, DC 20201,1-800-368-1019, 800-537-7697 (TDD) .

Complaint forms are available at https://www.hhs.gov/ocr/office/file/index.html .

Auxiliary aids and services, free of charge, are available to you. 1-866-396-8810 (TTY: 711)Humana provides free auxiliary aids and services, such as qualified sign language interpreters, video remote interpretation, and written information in other formats to people with disabilities when such auxiliary aids and services are necessary to ensure an equal opportunity to participate.


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