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 For Temporary use during COVID-19 restrictions

Healthfirst Enrollment
Agreement / Transfer Attestation
Healthfirst CompleteCare (HMO SNP) | Senior Health Partners, Managed Long-Term Care Plan

Member Information
Last Name First Name Middle Initial
Date of Birth Female Male Email
Address Apt. # City State Zip Code
Primary Phone Number ( ) Alternate Phone Number ( )
Medicaid No. SSN
Medicare No. Effective Dates Part A Part B Part C Part D
Name of Current Plan MLTC MMCP

Please check ( ü ) all that apply

I agree to participate in CompleteCare Senior Health Partners.
I understand that my date of enrollment is expected to be .
I understand that I have the right to change my mind and not enroll, and that I must contact Healthfirst immediately upon
deciding not to enroll.
I understand that I will receive a Member Handbook, which includes the rules and responsibilities of plan membership
and a description of covered services, prior to the plan effective date.
I will review the terms and conditions for plan enrollment stated in the Member Handbook.
I understand that I will receive a copy of the Notice of Privacy Practices, prior to the plan effective date.
I have been informed about and understand the Medicaid Excess Income Program (Spend-Down Program), which is
paid to Healthfirst.
I understand that I will be given a list of the providers in the provider network, and I agree to receive care
from the network of providers.
If I am or become a resident in a nursing facility, I agree to a referral to New York State’s contractor for Money Follows
the Person/Open Doors, a program that can work with my MLTC plan to help me return to community living.

Print Name of Participant/Enrollee Signature of Participant/Enrollee Date

Print Name of Family Member/Guardian or POA Signature of Family Member/Guardian or POA Date

Print Name of Witness Signature of Witness Date

Print Name of Healthfirst Representative Signature of Healthfirst Representative Date

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 For Temporary use during COVID-19 restrictions

For potential enrollees who do not speak English as a first language

I, , have read and translated this enrollment agreement/attestation

Translator’s Name
into a language speaks.
Enrollee’s Name

Signature Date

Please contact Healthfirst at 1-888-260-1010 if you need information in an accessible format or language other
than those listed. Our office hours are 7 days a week, 8am–8pm. TTY users should call 1-888-542-3821.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance
Company, Inc. (together, “Healthfirst”). Coverage for Senior Health Partners, Managed Long-Term Care Plan, is provided
by Healthfirst PHSP, Inc. Plans contain exclusions and limitations.
Healthfirst Health Plan, Inc. is an HMO plan with a Medicare contract and a contract with the New York Medicaid program.
Enrollment in Healthfirst Medicare Plan depends on contract renewal.
The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy
Network (ICAN) to provide Participants/Members free, confidential assistance on any services offered by Healthfirst
Health Plan, Inc. or Senior Health Partners Plan. ICAN may be reached toll-free at 1-844-614-8800 or online at
icannys.org. (TTY users call 711, then follow the prompts to dial 844-614-8800.)
Healthfirst complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex.
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al
1-866-305-0408 (TTY 1-888-867-4132).
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1-866-305-0408
(TTY 1-888-542-3821)。
H3359_ENR20_54 1826-19_M
© 2019 HF Management Services, LLC 1826-19_EN SHP20_24 1826-19 NYSDOH Approved 04202020

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