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Medicare Individual Enrollment Request Form

Please complete the information below. (*) indicates a required field.

I am
Eligibility Questions 

Typically, you may enroll in a Medicare Advantage plan during the annual enrollment period between November 15 and December 31 of each year. In addition, you can join a Medicare Advantage plan during the open enrollment period between January 1 and March 31 of each year, as long as you don’t add or drop your prescription drug coverage (i.e. if you have Medicare prescription drug coverage you can only change to another plan with Medicare prescription drug coverage; if you don’t have Medicare prescription drug coverage you can only change to another plan without Medicare prescription drug coverage). Additionally, there are exceptions that may allow you to enroll in a Medicare Advantage plan outside of these periods.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.















* Please contact Welborn Health Plans 7 days a week, 8 a.m. to 8 pm. at 1-800-521-0265 (TTY users should call 1-800-743-3333) to see if you are eligible to enroll.

Personal Information 
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Mailing Address 
  1. Do you have a different mailing address than the one listed above? *
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Please Provide Your Medicare Insurance Information
Please take out your Medicare Card to complete this section.

Please fill in these blanks 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.

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  4. Effective Date
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Choose a Primary Care Physician (PCP) from the plan's Provider Directory
Paying Your Plan Premium

You can pay your monthly plan premium by mail or “Electronic Funds Transfer” (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security benefit check each month.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover.

Payment Options

  2. Electronic funds transfer (EFT) from your bank account each month. For checking account withdrawal a VOIDED Check must be included with this application. For savings account withdrawal a Deposit Ticket must be included with this application. Download and print our Check Withdrawal Form, complete the form and then mail with a voided check or deposit ticket to Welborn Health Plans Enrollment Department 101 S.E. Third Street Evansville, IN 47708
  3. Automatic deduction from your monthly Social Security benefit check. (The Social Security deduction may take two or more months to begin. In most cases, the first deduction from your Social Security benefit check will include all premiums due from your enrollment effective date up to the point withholding begins.)

Please Read and Answer these Important Questions 
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STOP -- Please Read this Important Information 
  1. If you currently have health coverage from an employer or union, joining the WHP Silver Rx (HMO), WHP Platinum Rx (HMO) or the Platinum Select Rx (HMO-POS) could affect your employer or union health benefits. You could lose your employer or union health coverage if you join the WHP Silver Rx (HMO), WHP Platinum Rx (HMO) or the Platinum Select Rx (HMO-POS). 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.

Please Read and Sign Below 
  1. By completing this enrollment application, I agree to the following:
  2. <planname> 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.
  4. 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.
  5. <planname> serves a specific service area. If I move out of the area that <planname> 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 <planname>, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from <planname> when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren't usually covered under Medicare while out of the country except for limited coverage near the U.S. border.
  6. I understand that beginning on the date <planname> coverage begins, I must get all of my health care from <planname>, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by <planname> and other services contained in my <planname> Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR <planname> WILL PAY FOR THE SERVICES.
  7. I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with <planname>, he/she may be paid based on my enrollment in <planname>.
  8. Release of Information: By joining this Medicare health plan, I acknowledge that Welborn 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 <planname> 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.
  9. 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 <planname> or by Medicare.
  10. Please type your full name in the box below. This will be used in lieu of your written signature and will carry the same legal authority.
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Welborn Specialist Assistance 
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Authorized Representative 
  1. If you are the authorized representative, you must sign above and provide the following information:
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