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INDIVIDUAL ENROLLMENT REQUEST FORMCOMPLETE THIS FORM AND MAIL TO:Ohio Medicaid Consumer Hotline505 South High Street, Suite 200Columbus, Ohio 43215or FAX TO: (614) 280-0977QUESTIONS? Call (800) 324-8680To enroll in a MyCare Ohio Plan, you must haveMedicare Part A (Hospital Insurance), MedicarePart B (Medical Insurance), and Ohio Medicaid1. Choose the Medicare-Medicaid Plan you wish to enroll in:[Check the box next to the plan you want to enroll with.]BuckeyeCareSourceUnited2. Your information[Please fill in the spaces below. Be sure to print clearly.]Your Name [first, middle, last]Phone Number:Second phone number:Email address:Page 1
Home address:City:State:Emergency contact name:Zip Code:County:Emergency contact phone number:3. Tell us where you usually get health services:[Please print clearly.]Name of primary care provider, clinic, or health centerPrimary care provider phone Number:Page 2
MyCare Ohio: Individual Enrollment Request Form4. Tell us about your Medicare & Medicaid coverage:Fill in your Medicare and Medicaid information below. You can findthis information on your red, white, and blue Medicare card, or anotice from Social Security or the Railroad Retirement Board. Also,please put your Medicaid ID number as it appears on the front of yourcard.Medicaid ID number:Name:Medicare NumberSexIs entitled to:Effective Date[MM-DD-YYYY]HOSPITAL (Part A)HOSPITAL (Part B)5. Tell us how you want to receive your care:I want MyCare Ohio to provide BOTH myMedicaid and Medicare services.I want MyCare Ohio to provide my Medicaidservices ONLY.Page 3
MyCare Ohio: Individual Enrollment Request Form6. Please read and sign below.When you sign this form, it means you understand the following: MyCare Ohio plans have acontract with the federalgovernment and with Ohio. The health services youget with your new planmay be different than theservices you had before. I must keep Part A, Part B,and Ohio Medicaid. I can be in only oneMedicare plan at a time. By enrolling in MyCareOhio, I’ll end my enrollmentin another Medicare healthor prescription drug plan. I must tell Medicare andOhio Medicaid about anyprescription drug coveragethat I have or may get inthe future. If I move, I need to tell mycounty caseworker. As a member of MyCareOhio, I have the right toappeal if I don’t agree withmy plan’s decisions aboutpayment or services. I understand that myMyCare Ohio plan’smember handbookincludes the rules I mustfollow. The MyCare Ohio doesn’tusually cover peoplewhile they’re out of thestate, but there may besome limited coverageacross the Ohio stateborder. On the date my coveragebegins, I must get myhealth care from myplans providers, exceptfor emergency or urgentlyneeded care. My plan will cover myhealth care with theirnetwork providers andother providers as outlinedin their member handbook.Page 4
MyCare Ohio: Individual Enrollment Request Form If I need to see a provideror other provider who isn’tin in my plan’s network, Imay need priorauthorization or I may haveto pay out-of-pocket for theservices I get. By enrolling in a MyCareOhio plan, I know that myplan may share myinformation with Medicareand Ohio Medicaid andother plans as necessaryfor treatment, payment,and health care operations. I understand thatprescription drugs arecovered, but not always thesame ones I’m alreadytaking. I understand I’llhave access to my currentdrugs for at least 30 days,until I can switch todifferent drug. I know that my MyCareOhio plan may share myinformation, including myprescription drug eventYour signature:data, with Medicare andOhio Medicaid. They mayrelease it for research andother purposes, as allowedby federal statutes andregulations. The information on thisform is correct to the bestof my knowledge. Iunderstand that if Iintentionally provide falseinformation on this form, I’llbe disenrolled from MyCareOhio. My signature (or myauthorized representative’ssignature) on this formmeans that I’ve read andunderstood this form. If anauthorized representativesigns, the person’ssignature means that he orshe is authorized underState law to complete thisenrollment, anddocumentation of thisauthority is available uponrequest from Medicareand/or Ohio Medicaid.Date:Page 5
MyCare Ohio: Individual Enrollment Request FormInformation about your authorized representative, if applicable:If you’re the authorized representative, you must provide the followinginformation, sign, and date below.Name:[Please print.]Signature:Date:Address:Phone number:Relationship to person withMedicare and Medicaid:If you need more information, have questions, or need anyassistance with this form such as translation, call the OhioMedicaid Consumer Hotline at (800) 324-8680, Mondaythrough Friday 7:00 a.m. to 8:00 p.m. and Saturday 8:00 a.m.to 5:00 p.m., or visit www.ohiomh.com.Page 6
MyCare Ohio: Individual Enrollment Request FormNotice of NondiscriminationThe Ohio Department of Medicaid complies with applicable Federalcivil rights laws and does not discriminate on the basis of race, color,national origin, age, disability, or sex. The Ohio Department ofMedicaid does not exclude people or treat them differently because ofrace, color, national origin, age, disability, or sex.The Ohio Department of Medicaid: Provides free aids and services to people with disabilities tocommunicate effectively with us, such as:o Qualified sign language interpreterso Written information in other formats (large print, audio,accessible electronic formats, other formats) Provides free language services to people whose primary language isnot English, such as:oQualified interpretersoInformation written in other languagesIf you need these services, contact the Ohio Medicaid ConsumerHotline at 800-324-8680.If you believe that the Ohio Department of Medicaid has failed toprovide these services or discriminated in another way on the basis ofrace, color, national origin, age, disability or sex, you can file agrievance with:Ohio Department of MedicaidP.O. Box 182709Columbus, Ohio 43218-2709614-466-4693Page 7
MyCare Ohio: Individual Enrollment Request FormYou can also file a civil rights complaint with the U.S. Department ofHealth and Human Services, Office for Civil Rights, electronicallythrough the Office for Civil Rights Complaint Portal, available sf or by mail or phoneat:U.S. Department of Health and Human Services200 Independence Avenue SW.Room 509F, HHH BuildingWashington, DC 202011-800–368–1019, (TDD: 1-800–537–7697).Complaint forms are available e 8
English: ATTENTION: If you speak English, language assistance services, free ofcharge, are available to you. Call 1-800-324-8680. (TTY: 711).Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos deasistencia lingüística. Llame al 1-800-324-8680. (TTY: 711).Chinese: ��援助服務。請電 1-800-3248680 (TTY: 711)。German: ACHTUNG: Wenn Sie Deutsch sprechen, koennen Sie kostenlos Hilfe fuerSprachen zur Verfuegung haben. 1 800-324-8680 (TTY 711).Arabic: (TTY: 711) 1-800-324-8680 سيكون بامكانك استخدام خدمة المساعدة اللغوية المتاحة مجانا ً من , إذا كنت تتحدث العربية : مالحظة خالل االتصال بالرقم التالي Pennsylvanian Dutch: Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht,kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Rufselli Nummer uff: Call 1-800-324-8680. (TTY: 711).Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступныбесплатные услуги перевода. Звоните 1-800-324-8680. (телетайп: 711).French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sontproposés gratuitement. Appelez le 1-800-324-8680. (TTY: 711).Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, chúng tôi có các dịch vụ hỗ trợ ngônngữ miễn phí dành cho bạn. Gọi số 1-800-324-8680. (TTY: 711).Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii,kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-324-8680. (TTY: 711).Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로이용하실 수 있습니다. 1-800-324-8680 (TTY: 711) 번으로 전화해 주십시오.
Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi diassistenza linguistica gratuiti. Chiamare il numero 1-800-324-8680. (TTY: �だけます。1-800-324-8680（TTY: �。Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van detaalkundige diensten. Bel: 1-800-324-8680. (TTY: 711).Ukranian: УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутисядо безкоштовної служби мовної підтримки. Телефонуйте за номером 1-800-3248680. (телетайп: 711).Romanian: ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii deasistență lingvistică, gratuit. Sunați la 1-800-324-8680. (TTY: 711).Somali: DIGTOONI: Haddii aad ku hadasho Af Soomaali, adeegyada caawimadaluqadda, oo lacagla’aan ah, ayaa laguu heli karaa adiga. Wac 1-800-324-8680. (TTY: 711).Nepali: !यान iदनuहोस ्: तपार्इ01 2पा3ी बो6नu789 भ2 तपार्इ0को नन तत भाषासहायता वाह@ नiनःBu6क @पमा उप3Eध 9 । फोन गनuीहोस ् 1-800-324-8680(iदiदवार्इ: 711) ।
To enroll in a MyCare Ohio Plan, you must have Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance), and Ohio Medicaid 1. Choose the Medicare-Medicaid Plan you wish to enroll in: [Check the box next to the plan you want to enroll with.] Buckeye CareSource United 2. Your information [Please fill in the spaces below.
