How to complete a Paper Application

Y0040_GHA0AV6HH_12 CMS Approved 10032011

• This presentation is a guide for completing the paper application correctly.

• The information in this presentation is to be used only as a reference tool.

• You are not required to complete an application at this time.

Use

Important things to know:Something as simple as failing

to properly mark the application can cause the application to pend and delay the start of coverage.

• Use blue or black ink

• Fill in the circle completely

• Print clearly

• If you make a mistake mark it with an X, write the correct info above it.

• When adding a date do not use dashes or spaces

• Enter the ACH R/T number as your routing number

Marking

Medicare information: Take this directly from your Medicare CardThe information must match your Medicare card exactly.

Page 1 – Left side

In this section completely fill in the circle• Currently on Medicaid?

– If yes – fill in the yes circle and add your Medicaid number– If no – fill in the no circle and move to the plan section

• Name of plan you are enrolling in - Fill in the circle for Plan. The agent will review the plan name

• Plan option number – The agent will review this number. Plan name and plan option number can also be found on your Summary of benefits

Page 1 continued – Right side

Optional Supplemental Benefits• To add any of the optional supplemental benefits fill in the circle next to the

ones you want to enroll in.

Page 1 continued – Middle section

These are added benefits with an additional cost

• Language preference – Select the language you would like Humana customer service to use when you call in for information.

• Residential address – This must be a physical address – do not list a PO Box in this field. The county must also be listed

• Telephone number – This should be a number that Humana can use to contact you.

• Date of birth - This will be 2 digit month, 2 digit day and 4 digit year.

• Sex – Fill in the circle that matches your gender

• Mailing address – only complete this section if your mailing address is different then your residential address. A PO Box can be used for the mailing address.

Page 1 continued – Bottom section

Every page of the application will require your Medicare ID number• Other contact information (optional) – enter the number that the Humana agent can best

contact you and select what time of day• Email address – this is optional

– The email address will allow Humana to send you non-enrollment plan materials via e-mail. Ex: New Member Orientation invitation

• Person to Notify in an Emergency – optional field• Primary Care Physician (PCP) – this is only needed if enrolling in an HMO plan.

– The agent can look up the PCP number in the provider directory

Page 2 – Top section

Answer Yes or No to every question • If the answer is Yes to any question additional information will be needed.• Question 1 – Other medical health coverage once enrolled. This is referring you or

your spouse. If your spouse will have coverage, the answer should be Yes.

Page 2 – Middle section

If YES complete all information.This information should be listedon the ID card for that company

• Enter Medicare ID number• Answer Yes or No to each question. If you answer Yes, additional information will be

required.• Question 4 – End Stage Renal disease. If you answer Yes, a note from the doctor will

be required, stating you no longer need dialysis or that you have had a kidney transplant.

• Question 5 – resident in a nursing home. If the answer is Yes, please provide the facility information.

Page 3 – Top section

Select how you would like to pay for the plan• Social Security deduction – only requires marking the circle.• Coupon book – only requires marking the circle.• Electronic Fund Transfer (Bank deduction) – will require bank information in

Depository section.• Auto Credit Card Charge (Credit card payment) – will require credit card information.

Page 3 – Bottom section

Page 4 – Special Election Period (SEP)

• Enter your Medicare ID number.

• If this is not your Initial Enrollment or the Annual Enrollment, you may be using a Special Election Period.

• If your current plan is no longer offered, select NON on the SEP list.

• If you are unsure of your election period, please ask the agent.

• Enter your Medicare ID number.

• Page 5 and 6 are review pages that only require your Medicare ID number.

Page 5 and 6

• Enter your Medicare ID number

• Signature of applicant – this is the person being insured or the Power of Attorney for the insured– If unable to sign your name you may just put an X (two witnesses must sign)

Page 7 – Signature

Signature date – this isthe date the application was signed

Thanks for your time and attention.

Any questions?

The person that is discussing plan options with you is either employed by or contracted with Humana. The person may be compensated based on your enrollment in a plan.

The Humana family has Health plans with a Medicare contract, available to anyone enrolled in both Part A and Part B of Medicare. The Humana family has stand-alone prescription drug plans with a Medicare contract, available to anyone entitled to Part A and/or enrolled in Part B of Medicare. Medicare beneficiaries, except for Group Medicare or Special Needs Plans, may enroll in the plan only during specific times of the year. Contact Humana for more details.

This information is available for free in other languages. Please contact our Customer Care number at 1-800-457-4708 (TTY: 711) for additional information.

Esta información está disponible gratuitamente en otros lenguajes. Póngase en contacto con nuestro Departamento de Atención al Cliente al 1-800-457-4708 (TTY: 711) si desea mayores informes.

GHA0AV6HH_12 09/11