Need Information?

Call us during business hours at (877) 211-6614, TDD(800) 577-5586 to speak with a live representative.

Want some good reasons to join CareMore? How about starting with your good health?

Member Enrollment Form (part 1 of 5)

Please complete the form below and we'll reply to you as soon as possible.

All fields must be completed.

Basic Information

Salutation

Last Name

First Name

M.I.

Permanent Residence Address

City

Zip Code

Mailing Address

City

Zip Code

Phone (###-###-####)

Permanent Residential County

Los Angeles County

Orange County

        I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the State where the individual resides) on this application means that I have read and understand the contents of this applications.  Including the "Statement of Understanding" on the back of this form.  If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State of law to complete this enrollment and 2) documentation of this authority is available upon request by California Medicare Advantage HMO and by Medicare.
        Release of Information
        By joining this medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicareand other plans as necessary for treatment, payment and health care operations.  The information on this enrollment form is correct to the best of my knowledge.  I understand that if I intentionally provide false informationon this form, I will be disenrolled from the plan.  My enrolling also authorizes any California Medicare Advantage HMO provider of service (or anyone else who has medical information about me), as those terms are defined in the California Civil Code, to release my medical records, including any substance abuse and/or psychiatric disorders or other required information to CMS and Californa Medicare Advantage HMO to administer Title XVII of the Social Security Act.  This authorization will remain valid for the term of coverage with California Medicare Advantage HMO.
        A copy of this authorization is as valid as the original.  My authorized representative and I are entitled to receive a copy of this authorization.

Do you agree to the terms above?

	Yes
	No