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Medicare application PDF Form: What You Should Know
We will use this information you provide to determine who will manage your benefits. What can Medicare do with my information? We can use your information to make sure that beneficiaries who are covered under certain Medicare programs are receiving the appropriate benefits, and to assist Medicare and Medicaid managed care organizations (MCO) in carrying out their Medicaid and Medicare underwriting responsibilities. How are my information used? We use information you provide on this form in the following places for the following purposes and for Medicare enrollment and enrollment referrals only. To calculate payments to Medicare and Medicare Part B recipients (Part of Medicare) To enroll in Medicare or Medicaid programs (Part of Medicare) To provide Medicare enrollment referrals and enrollment information (Part of Median) How is my information protected? The information you do not give us can still be used to enroll you for Medicare and help us provide you with health care, if you request that we do so. We will protect your information. If we learn of any loss or abuse of your information, we will notify you by letter or other appropriate means. When will I receive my Medicare benefit? Medicare will provide your Medicare benefit to you either by mail or over the telephone; you cannot receive it if you do not have a Medicare card. If you or the person to whom you are applying for Medicare has been notified that you are enrolled in Part B or Supplemental Security Income, you will receive Medicare benefits on the date that you or the person you are enrolling sends your application for enrollment, and we receive it. We will take actions to keep your personal information confidential, and we will use reasonable best efforts to protect it until you receive the benefits payable to you. How long will it take for me to receive my benefits? Your Medicare benefits will be paid to a new provider and will begin the first day the payment is made by Medicare. I am not sure if I qualified for Medicare, but I would like to find out (Medicare does not give us this information but if I apply for benefits, they will tell me about it). Can I find out if I qualify for Medicare through this form? Yes, as long as you sign the form (including giving us permission to use your information), you can receive information on your eligibility for Medicare benefits. This form is for your personal use and does not belong to you.
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