Plan Premium 1=EGID will bill the 61 849 849 1 A/N Y 1 Payment Option member Member is ESRD Y=Yes 62 850 850 ESRD 1 A/N Y N=Blank Medicare Info Datasheet Default=N or <Blank> Language preference or another format other than English Request Materials Y=Yes 63 851 851 in Language Other 1 A/N Y N-No MAPD will contact the Than English Beneficiary if the box on the enrollment form is marked ‘Yes’ Medicare Info Datasheet Language Default=N Preference and 64 852 852 1 A/N Y N=No Alternative NOT USED Formats Form is signed. Beneficiary Signature and/or Default to Y 65 853 853 Authorized 1 A/N Y Y=Yes since no enrollments will Representative be sent if form is not Signature signed. 1) Medicare Info Datasheet 2) Person record is Authorized dependent child use – 66 854 903 Representative 50 A/N Y Primary Member’s Last Name Indicative Info 3) <blank> 1) Medicare Info Datasheet 2) Person record is Authorized dependent child use – 67 904 953 Representative 50 A/N Y Primary Member’s First Name Indicative Info 3) <blank> 1) Medicare Info Datasheet 2) Person record is Authorized dependent child use – 68 954 954 Representative 1 A/N Y Primary Member’s Middle Initial Indicative Info 3) <blank> 1) Medicare Info Datasheet 2) Person record is Authorized dependent child use – 69 955 1014 Representative 60 A/N Y Primary Member’s Address1 Indicative Info 3) <blank> Authorized 1) Medicare Info Datasheet 70 1015 1044 Representative 30 A/N N 2) Person record is Address2 dependent child use –
61 849 849 Plan Premium Payment Option 1 A/N Y 1 1=EGID will bill the member 62 850 850 ESRD 1 A/N Y Y=Yes N=Blank Member is ESRD Medicare Info Datasheet 63 851 851 Request Materials in Language Other Than English 1 A/N Y Y=Yes N-No Default=N or <Blank> Language preference or another format other than English MAPD will contact the Beneficiary if the box on the enrollment form is marked ‘Yes’ Medicare Info Datasheet 64 852 852 Language Preference and Alternative Formats 1 A/N Y N=No Default=N NOT USED 65 853 853 Beneficiary Signature and/or Authorized Representative Signature 1 A/N Y Y=Yes Form is signed. Default to Y since no enrollments will be sent if form is not signed. 66 854 903 Authorized Representative Last Name 50 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> 67 904 953 Authorized Representative First Name 50 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> 68 954 954 Authorized Representative Middle Initial 1 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> 69 955 1014 Authorized Representative Address1 60 A/N Y 1) Medicare Info Datasheet 2) Person record is dependent child – use Primary Member’s Indicative Info 3) <blank> 70 1015 1044 Authorized Representative Address2 30 A/N N 1) Medicare Info Datasheet 2) Person record is dependent child – use
Solicitation0900000302Attachment7.docx