Atrio Health Plans

We are moving to a NEW location on July 26, 2010: 2270 NW Aviation Dr. Suite 3
Across from Aviation Suites at Roseburg Regional Airport

Questions? or To request an Exception or Appeal Call Customer Service:
Toll-Free: 877-672-8620 TTY: 800-735-2900
Monday - Friday, 8am to 5pm PT

Home >>> Prospective Members >>> Online Enrollment

Online Enrollment

Please provide your personal information:

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Last Name	First Name

Middle Initial	Birth Date (MM/DD/YYYY)

Sex Male Female

Home Phone Number	Alternate Phone Number


Emergency Contact Name	Relationship to You

Phone Number	E-mail Address

Permanent Residence Street Address


City	State	Zip Code

Mailing Address
(if different from your Permanent Residence Address)


City	State	Zip Code

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Please Provide Your Medicare Insurance Information:

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Please take out your Medicare Card to complete this section.
Please fill in these fields 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.

Name	Sex Male Female

Medicare Claim Number

Is Entitled To Effective Date:

HOSPITAL (Part A)	MEDICAL (Part B)

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Please Read This Important Information:

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If you currently have health coverage from an employer or union, joining ATRIO Health Plans could affect your employer or union health benefits. You could lose your employer or union health coverage if you join ATRIO Health Plans. If you have health coverage from an employer or union, joining ATRIO Health Plans may change how your current coverage works. 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.

By completing this enrollment application, I agree to the following:
ATRIO Health Plans 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.

(only if choosing MyAdvantage Active or MyAdvantage II):
I understand that if I do not have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage 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: November 15 – December 31 of every year), or under certain special circumstances.

ATRIO Health Plans serves a specific service area. If I move out of the area that ATRIO Health Plans serves, I need to notify the plan so I can disenroll and find a new plan in my new area.

Once I am a member of ATRIO Health Plans, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from ATRIO Health Plans when I receive it to know which rules I must follow in order to receive coverage with this Medicare Advantage plan.

I understand that people with Medicare beneficiaries are generally not covered under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date ATRIO Health Plans coverage begins, I must get all of my health care from ATIRO Health Plans, with the exception of emergency or urgently needed services or out-of-area dialysis services.

Services authorized by ATRIO Health Plans and other services contained in my ATRIO Health Plans Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR ATRIO Health Plans WILL PAY FOR THE SERVICES.

I understand that if I am receiving assistance from a sales agent, broker, or other individual employed by or contracted with ATRIO Health Plans, he/she may be paid based on my enrollment in ATRIO Health Plans.

Counseling services may be available in my state to provide advice concerning Medicare supplement insurance or other Medicare Advantage or Prescription Drug plan options as well as medical assistance through the state Medicaid program and the Medicare Savings Program.

Release of Information:
By joining this Medicare health plan, I acknowledge that the Medicare health plan ATRIO Health Plans will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that ATRIO Health Plans 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.

*Signature (type your name here)
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 application means that I have read and understand the contents of this application. 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 by ATRIO Health Plans or by Medicare.

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

Name

Phone Number

Address

Relationship to Enrolee

If an Insurance Agent assisted with this enrollment,
please provide Agent Name or Agent Code:

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Please Review and Verify All Information Before Submitting

(click "Edit" to make changes)

Selected Plan:

Edit (1)

Personal Information

Edit (2)

Last Name:
First Name:
Middle Initial:
Birth Date:
Sex:
Home Phone:
Alternate Phone:
Permanent Residence Street Address:
City:
State:
Zip Code:
Mailing Address (if different from above):
City:
State:
Zip Code:
Emergency Contact:
Emergency Contact Phone:
Relationship to You:
E-Mail Address:

Questions and Answers

Edit (5)

Do you have End-Stage Renal Disease (ESRD)?
Will you have other prescription drug coverage in addition to the plan you are applying for?
Name of other coverage:
ID number for this coverage:
Group number for this coverage:
Are you a resident in a long-term care facility, such as a nursing home?
Name of Institution:
Address of Institution:
Phone Number of Institution:
Are you enrolled in your State Medicaid program?
If yes, your State Medicaid number:
Do you or your spouse work?

Release of Information

Edit (7)

Release of Information:
Date of Application:
Name of Authorized Representative:
Representative Address:
Representative Phone:
Representative Relationship to Enrollee:
Insurance Agent Assistance:

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H3814_MKG 50_03
CMS Approved: 10/20/09
Date Last Updated: 11/15/2009

Douglas and Klamath Counties Only:	Washington County Only:

ATRIO MyAdvantage Active (HMO) ATRIO MyAdvantage Active Rx (HMO) ATRIO MyAdvantage II (HMO) ATRIO MyAdvantage II Rx (HMO) ATRIO MyAdvantage Elite Rx (HMO-POS) ATRIO MyAdvantage Choice Rx (HMO-POS) ATRIO MyAdvantage Special Needs Plan (HMO)	ATRIO Tuality MyAdvantage Active (HMO) ATRIO Tuality MyAdvantage Active Rx (HMO) ATRIO Tuality MyAdvantage II (HMO) ATRIO Tuality MyAdvantage II Rx (HMO) ATRIO Tuality MyAdvantage Elite Rx (HMO-POS) ATRIO Tuality MyAdvantage Choice Rx (HMO-POS) ATRIO Tuality MyAdvantage Companion (HMO)