Please read all of the following terms and disclosures before continuing.

People with Current Health Coverage

If you currently have health coverage from an employer or union, joining RMHP could affect your employer or union health benefits. If you have health coverage from an employer or union, joining may change how your current coverage works. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn't any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

By completing this enrollment application, I agree to the following:

Rocky Mountain Health Plans is a Medicare health plan and I will need to keep my Medicare Part B. I can be in only one Medicare health plan at a time. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I know I may disenroll from this plan at any time by sending a written request to RMHP or by calling 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
RMHP serves a specific service area. If I move out of the area that RMHP serves, I need to notify the plan so I can disenroll and find a new plan in my new area.
Once I am a Member of RMHP, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from RMHP when I receive it to know which rules I must follow in order to get coverage with this Medicare health plan.
I understand that beginning on the date RMHP coverage starts, in order for RMHP to cover my medical services (except for emergency or urgently-needed services), all of my health care must be provided or arranged by RMHP. If I obtain services not provided or arranged by the plan, I will be responsible for all Medicare deductibles and coinsurance, as well as any additional charges as prescribed by the Medicare program. I may also be liable for charges not covered by Medicare.
Medicare beneficiaries are generally not covered under Medicare while out of the country except for limited coverage in Canada and Mexico. Services authorized by RMHP and other services contained in my RMHP Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered.

Release of Information

By joining this Medicare health plan, I acknowledge that RMHP will release my information to Medicare and other plans as is 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 information on this form, I will be disenrolled from the plan.

I understand that my signature (or the signature of the person authorized to act on my behalf under the State law where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request by Rocky Mountain Health Plans or by Medicare.

Apply For Medicare with Rocky Mountain Health Plans

Apply For Medicare with Rocky Mountain Health Plans