Step 1: Please fill out all 6 pages of the application completely.

Step 2: Sign and date the last page of the application.

Step 3: Please make a copy of the application for your records.

Step 4: Mail the original copy to the health plan. You can call the plan to request a pre-paid envelope (no stamp needed).

(Please note: By clicking on this link you will be leaving the Advantage by Bridgeway Health Solutions HMO SNP website.)

2012_Enrollment_Form

If you have any questions regarding this application, please contact Member Services (number listed on the right) and ask to speak with a Sales Representative *

By asking to speak with a sales agent, you will be directed to a licensed insurance agent/broker. You are not required to speak with a sales agent. You can speak with a Member Service Representative to receive plan information.

For enrollments after October 1, 2011, effective dates November or December 1, 2011: Benefits formulary, pharmacy, network, premium and/or co-payments/co-insurance may change on January 1, 2012. Please contact Advantage by Bridgeway Health Solutions HMO SNP for more information.

Notice of Possible Contract Termination Disclaimer

By law Advantage by Bridgeway Health Solutions HMO SNP (Bridgeway) can choose to not renew our contract with the Centers for Medicare & Medicaid Services (CMS). CMS may also refuse to renew the contract, thus resulting in a termination or non-renewal. If either of these scenarios occur, this may result in termination of beneficiary enrollment in the plan. In addition, Bridgeway may reduce its service area and no longer offer services in the area where a beneficiary resides.

IMPORTANT INFORMATION

Advantage by Bridgeway Health Solutions HMO SNP (Bridgeway) will not be serving Yuma County effective January 1, 2012. You may choose to enroll in our plan, but your coverage will automatically end on December 31, 2011. Because this plan ends on December 31, 2011 if you decide to join, you are entitled to enroll in a new MA plan or PDP beginning December 8 , 2011 through February 29, 2012. However, if you want your enrollment in the new plan to take effect on January 1, 2012 the new plan must receive your application by December 31st. You may also have the option of enrolling in a Medicare Cost Plan, if one is offered in your area. If you do not enroll in another MA plan, Medicare Cost Plan or PDP plan by December 31, 2011 you will be disenrolled from our plan and enrolled in Original Medicare on this date. You will receive additional information in the fall about your rights and additional options.

Last Updated: 2/02/2012