Get Act Essence If You Need Information In Another L Anguage Or Format (braille, Large Prrint, Etc

This guide provides step-by-step instructions for completing the Act Essence form online, ensuring users can easily request information in alternative formats such as Braille or large print. Follow these instructions to navigate through the form efficiently and accurately.

Follow the steps to fill out the form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Start by indicating the plan you want to enroll in by checking the appropriate box for either Essence Advantage® HMO or Essence Advantage Pluss® HMO. Provide the last name, first name, birth date, sex, and middle initial.
3. Fill out the home phone number, permanent residence street address, city, county, state, and zip code. If your mailing address differs from your permanent residence, provide the mailing street address and city.
4. Provide an emergency contact name and their relationship to you, along with their phone number and address.
5. Complete the Medicare insurance information section by entering your name, Medicare claim number, and effective dates for both Medicare Part A and Part B. Ensure you attach a copy of your Medicare card.
6. Select your preferred method of paying the plan premium, either via mail, Electronic Funds Transfer (EFT), credit card, or automatic deduction from Social Security benefits.
7. Answer important questions regarding End Stage Renal Disease, other drug coverage, long-term care residency, and Medicaid enrollment.
8. Choose the name of your primary care physician from the options provided and indicate if they are your current physician.
9. Review the important information section and ensure you understand the implications of joining the plan. Then, sign and date the application.
10. If applicable, provide the authorized representative's information, including their name, relationship to you, phone number, and address.
11. Once all sections are filled out, review the entire form for accuracy. Save your changes, download, print, or share the completed form as needed.

Complete your form online today to ensure you receive the necessary information in your preferred format.