Angel's Checklist

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1) I am aware that the Sales Agent I am working with is a licensed representative of my plan and does not represent Medicare or any branch of the federal or state government. When my enrollment is complete, the Sales Agent may be paid a fee. *

I Agree I Disagree

2) I understand that my plan will now provide all my plan will now provide all my Medicare health and/or prescription drug coverage and that the plan I have chosen in NOT a Medicare Supplemental (Medigap) Plan. *

I Agree I Disagree

15) For Special Needs (SNP) Plans: These Plans have rules about who can join them. Chronic Special Needs Plan: I can enroll in this type of Plan if I have already been diagnosed with one of these conditions: diabetes and/or heart failure or cardiovascular disorders. Dual Special Needs Plans: I can enroll in this type of plan if I have full Medicaid coverage ($0 cost share Dual Eligible). *

I Agree I Disagree

16) The company I’m enrolling with will call or write to me in 10-15 days. My Sales Agent has explained this process is an Outbound Enrollment Verification (OEV) that is a required confirmation to ensure I understand I have enrolled in a plan. *

I Agree I Disagree

17) If my situation changes and I am no longer eligibility for this plan, I will be disenrolled. My plan will work with me to find a plan that fits my new situation. *

I Agree I Disagree

18) My Sales Agent verified my Medicaid eligibility. *

Option 1 Option 2 Option 3

19) If my plan is unable to confirm my eligibility for this plan prior to enrollment, my application will be denied. *

I Agree I Disgree

20) My Sales Agent explained the enrollment cancellation process to me. *

I Agree I Disagree

21) If my enrollment application is incomplete for any reason, I will receive a letter and/or a call from the health plan asking me to provide the missing information. This may delay my enrollment in the plan. *

I Agree I Disagree

Enrollee Statement: By signing this form, I confirm that my Sales Agent has explained my plan benefits and reviewed the information in the enrollment booklet, including the multi-language insert, Star Ratings program, formulary, disclaimers and important contact information. I have full opportunity to ask questions. I understand that by complementing this application, I am applying to enroll in the plan. I know that if I have additional questions, I may call my Sales Agent or Customer Service. I will receive a copy of my enrollment application within 10 days after enrolling in this plan. *

I Agree I Disagree

Printing your name below, constitutes as your electronic signature and agreement that you agent, Angel Smart covered each of these areas with you today.

Name *

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I UNDERSTAND AND AGREE