Please contact Virginia Premier Advantage Gold (HMO) if you need information in another language or format (braille).

Release of Information: By joining this Medicare health plan, I acknowledge that Virginia Premier Advantage Gold (HMO) will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Virginia Premier Advantage Gold (HMO) 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.

Virginia Premier Advantage Elite (HMO SNP)
$0.00 Per month
Virginia Premier Advantage Gold (HMO)
$0.00 Per month
Virginia Premier Advantage Platinum (HMO)
$29.00 Per month
Please Provide the following information.
Requested Effective Date:*

Mr   Mrs   Ms         Last Name:*     Middle Initial:    First Name: *                         
Birth Date:*            *Gender: M    F Home Phone Number:
Enrollee Email Address:
Alternative Phone Number:
Permanent Residence Street Address: (P.O. Box is not allowed):* Apt # :
City or County:* State:* ZIP Code:*
Mailing Address:
(Only if different from your Permanent Residential Address)

Apt #:
City or County: State: ZIP Code:
Optional Field: Emergency Contact: Relationship to You:
Phone Number:
Please Provide Your Medicare Insurance Information:

Please take out your Medicare card for this section.

  • Fill out this information as it appears on your Medicare card.

- OR -

  • Attach a copy of your Medicare card or your letter from Social Security or the Railroad Retirement Board.


 

NAME OF BENEFICIARY:
MEDICARE CLAIM NUMBER:* *Sex:
Is Entitled To                                    Effective Date
HOSPITAL                             (PART A)
MEDICAL                               (PART B)
 
You must have Medicare Part A and Part B to join a Medicare Advantage plan.

Material ID:H9877_0519-MEFR-800068_C

Updated Date:October 14, 2019