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1 of 4 Personal

First, tell us a bit more about yourself.

Date of Birth (*Required)
Gender (*Required)

Permanent Residence Street Address

Must be a street address, not a P.O. Box

Your Medicare Information

Let's check if you can join a plan right now.

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

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.

Date of move (*Required)
Date released (*Required)
Date of return (*Required)
Date of status change (*Required)
Date of change (*Required)
Date of change (*Required)
Date of move (*Required)
Date I left (*Required)
Date coverage changed (*Required)
Date leaving (*Required)
Date current plan started (*Required)
Date SNP ended (*Required)

If none of these statements applies to you or you’re not sure, please contact Devoted Health at 1-800-990-0723 (TTY 711) to see if you are eligible to enroll. We are open 8am to 8pm, Monday to Friday (from October 1 to March 31, 8am to 8pm, 7 days a week).

Answer These Important Questions

Will you have other prescription drug coverage (like VA, TRICARE) in addition to your Devoted Health plan? (*Required)
Are you enrolled in your state Medicaid program? (*Required)

Fill out this section to help us better serve you.

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Choose your Language and Format

Select one if you want us to send you information in a language other than English.

Select one if you want us to send you information in an accessible format.

Please contact Devoted Health at 1-800-990-0723 (TTY 711) if you need information in an accessible format other than what’s listed above. We are open 8am to 8pm, Monday to Friday (from October 1 to March 31, 8am to 8pm, 7 days a week).

Do you work?
Does your spouse work?

Who's your Primary Care Provider?

This is the main doctor you see for your care. To make for the easiest start with your new plan, please tell us about your PCP. If you leave this section blank, we’ll choose a PCP for you.

Paying Your Plan Premiums

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T pay Devoted Health the Part D-IRMAA.

How would you like to pay?

*May take at least 2 months to start. The first deduction usually includes all premiums due up to that point.

IMPORTANT: Read and Sign Below

  • I must keep both Hospital (Part A) and Medical (Part B) to stay in Devoted Health
  • By joining this Medicare Advantage Plan, I acknowledge that Devoted Health will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below).
  • Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
  • 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.
  • I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border.
  • I understand that when my Devoted Health coverage begins, I must get all of my medical and prescription drug benefits from Devoted Health. Benefits and services provided by Devoted Health and contained in my Devoted Health “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Devoted Health will pay for benefits or services that are not covered.
  • I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that:
    • This person is authorized under State law to complete this enrollment, and
    • Documentation of this authority is available upon request by Medicare
Please tell us who you are. (*Required)

Authorized Representative

Please fill in the information below. The Enrollee is the person you're helping sign up for this plan.

Address