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Online Enrollment Costa County (Step {{step}} of 6)

Online Enrollment Costa County (Step 6 of 6)

Online Enrollment Completed


You are completing an actual enrollment request to Golden State Medicare Health Plan.

Enrolling online is safe & secure. All your information is encrypted.

Personal Information

Please contact Golden State Medicare Health Plan if you need information in another language or format (Braille).

To enroll in Golden State Medicare Health Plan, please provide the following information:

All lines marked with an asterisk (*) are required.

Mr. Mrs. Ms.
Male Female

Medical Insurance Information

Please take out your red, white and blue Medicare card to complete this section.

Please fill in the blanks so they match your red, white and blue Medicare card.

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

All lines marked with an asterisk (*) are required.

Paying your plan premium

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail each month or quarterly. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month. If you are assessed a Part D-Income Related Monthly Adjustment Amount, you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay Golden State Medicare Health Plan the Part D-IRMAA.

People with limited incomes may qualify for extra help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don't even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn't cover. If you don't select a payment option, you will get a bill each month.

Please select a premium payment option:

I get monthly benefits from  
(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from your enrollment effective date up to the point withholding begins. If Social Security or RRB does not approve your request for automatic deduction, we will send you a paper bill for your monthly premiums.)

Important Questions

Please read and answer these important questions

All lines marked with an asterisk (*) are required.

Yes No

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please check here.

We may need to contact you to obtain additional information.


2. Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.
Yes No

If "yes", please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage
Id for this coverage
Group for this coverage
Yes No

If "yes", please provide the following information

Name of Institution
Address & Phone Number of Institution (number and street)
Yes No
If yes, please provide your Medicaid number
Yes No

6. Please choose the name of a Primary Care Physician (PCP) and Medical Group/IPA: (optional)
Primary Care Physician
Medical Group/IPA
7. Please check one of the boxes below if you would prefer us to send you information in a language other than English or in another format:
Spanish Braille Large print

Please contact Golden State Medicare Health Plan at (877) 541-4111 toll free if you need information in another format or language than what is listed above. Our office hours are 8 a.m. to 8 p.m. Monday through Friday and daily during the enrollment period. TTY users should call 711.


8. Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period. If you are applying for a Special Election Period (SEP), please select one of the options on the following page.

Attestation Of Eligibility For An Enrollment Period

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.









I moved/will move into/out of the facility on









If none of these statements applies to you or you’re not sure, please contact Golden State Medicare Health Plan. at (877) 541-4111 (TTY users should call 711) to see if you are eligible to enroll. We are open 8 a.m. to 8 p.m. Monday through Friday and daily during the enrollment period.

Please Read This Important Information

If you currently have health coverage from an employer or union, joining Golden State Medicare Health Plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Golden State Medicare Health Plan. 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 benefit administrator or the office that answers questions about your coverage can help.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

Please read and confirm your understanding

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

Golden State Medicare Health Plan is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time, and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: October 15th - December 7th of every year), or under special circumstances.

Golden State Medicare Health Plan serves a specific service area. If I move out of the area that Golden State Medicare Health Plan 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 Golden State Medicare Health Plan, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage document from Golden State Medicare Health Plan when I get it to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren't usually covered under Medicare while out of the country except for limited coverage near the U.S. border.

I understand that beginning on the date Golden State Medicare Health Plan coverage begins, I must get all of my health care from Golden State Medicare Health Plan, except for emergency or urgently needed services or out-of-area dialysis services. Services authorized by Golden State Medicare Health Plan and other services contained in my Golden State Medicare Health Plan Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR Golden Golden State Medicare Health Plan WILL PAY FOR THE SERVICES.

I understand that if I am getting assistance from a sales agent, broker or other individual employed by or contracted with Golden State Medicare Health Plan, he/she may be paid based on my enrollment in Golden State Medicare Health Plan.

Release of Information: By joining this Medicare health plan, I acknowledge that Golden State Medicare Health Plan will release my information to Medicare and other plans as is necessary for treatment, payment and health care operations. I also acknowledge that Golden State Medicare Health Plan will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. 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 e-signature (or the e-signature of the person authorized to act on my behalf under the laws of the State 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 e-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 from Medicare.

If you are the authorized representative, you must check above and provide the following information:

First Name *
Last Name *
Address *
Phone Number *
Relationship to Enrollee*

By clicking "Enroll Now", you will be enrolled if approved by the Centers for Medicare & Medicaid Services
and will receive notice of acceptance or denial following submission of the enrollment form to CMS.

Thank you for enrolling in Golden State medicare Health Plan !
Your comfirmation number is {{enrollData.ConfirmationNumber}}
If you have any questions, please call Golden State Medicare Health Plan toll-free
at (877) 541-4111 TTY: 711 8:00 AM to 8:00 PM
Monday - Friday, and daily during the enrollment periods.
We were unable to enroll now.

For questions or assistance completing the enrollment form, please call Golden State Medicare Health Plan Member Services, toll-free at (877) 541-4111, TTY at (877) 551-4111, 8 AM to 8 PM Monday through Friday and daily during the enrollment /disenrollment periods.

Medicare beneficiaries may also enroll in Golden State Medicare Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-877-541-4111 (TTY: 1-877-551-4111). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüistica. Llame al 1-877-541-4111 (TTY: 1-877-551-4111). 注 意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-877-541-4111(TTY:1-877-551-4111)。CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-541-4111 (TTY: 1-877-551-4111). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-541-4111 (TTY: 1-877-551-4111). 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-541-4111 (TTY: 1-877-551-4111) 번으로 전화해 주십시 오. ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-877-541-4111 (TTY (հեռատիպ)՝ 1-877-551-4111): .‫باشد‬ ‫می‬ ‫فراھم‬ ‫شما‬ ‫برای‬ ‫رایگان‬ ‫بصورت‬ ‫زبانی‬ ‫تسھیلات‬ ،‫کنید‬ ‫می‬ ‫گفتگو‬ ‫فارسی‬ ‫زبان‬ ‫بھ‬ ‫اگر‬ :‫توجھ‬ 4111-541-877-1 ‫با‬ (TTY: 1-877-551-4111) ‫بگیرید‬ ‫تماس‬. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-541-4111 (телетайп: 1-877-551-4111).注意事項:日本語を話される場合、無料の言語支援をご利用いただけま す。1-877-541-4111(TTY:1-877-551-4111)まで、お電話にてご連絡ください。‫لك‬ ‫تتوافر‬ ‫اللغویة‬ ‫المساعدة‬ ‫خدمات‬ ‫فإن‬ ،‫اللغة‬ ‫اذكر‬ ‫تتحدث‬ ‫كنت‬ ‫إذا‬ :‫ملحوظة‬ 4111-551-877-1 :‫والبكم‬ ‫الصم‬ ‫ھاتف‬ ‫)رقم‬ 4111-541-877-1 ‫برقم‬ ‫اتصل‬ .‫)بالمجان‬. LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-541-4111 (TTY: 1-877-551-4111).ប្រុងប្រយ័ត្នៈបើសិនជាអ្នកនិយាយភាសាខ្មែរសេវាកម្មជំនួយភាសាគឺមិនគិតថ្លៃទេ។ ទូរស័ព្ទមកលេខ 1-877-541-4111 (TTY: 1-877-551-4111)។ ध्यान दें: यिद आप िहंदी बोलते हैं तो आपके िलए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-877-541-4111 (TTY: 1-877-551-4111) เรยน: ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-877-541-4111 (TTY: 1-877-551-4111).