Important: Read and Sign Below

I must keep both Hospital (Part A) and Medical (Part B) to stay enrolled in Solis Health Plans.
By joining this Medicare Advantage Plan, I acknowledge that Solis Health Plans will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by federal law that authorize the collection of this information (see Privacy Act Statement below). Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
I understand that I can be enrolled in only one MA plan at a time, and that enrollment in this plan will automatically end my enrollment in another MA plan. (Exceptions apply for MA PFFS, MA MSA plans.)
I understand that when my Solis Health Plans coverage begins, I must get all of my medical and prescription drug benefits from Solis Health Plans. Benefits and services provided by Solis Health Plans and contained in my Solis Health Plans “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Solis Health Plans will pay for benefits or services that are not covered.
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 legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (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 Medicare.

Signature *

By entering my name, I confirm my electronic signature on this form:

Authorized Representative? *

I am filling the application for myself

I am an Authorized Representative

You are now leaving
Solis Health Plans

You will be redirected to

here is the url

By clicking the link below to continue, you will be leaving Solis Health Planswebsite and going to another site unaffiliated with Solis Health Plans. If you do not wish to leave Solis Health Plans site, simply click “Cancel.” Thank you.

Solis Health Plans provides links to web sites of other organizations in orderto provide visitors with certain information. A link does not constitute an endorsement of content, viewpoint, policies, products or services of that website. Once you link to another web site not maintained by Solis Health Plans, you are subject to the terms and conditions of that website, including but not limited to its privacy policy.

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Enrollment

Before you start the Enrollment Application, please ensure you have the following documents:

Your Personal Contact Details.

Medicare ID Card: You must have Parts A and B to enroll in a Medicare Advantage plan.

Supporting Documents: Examples such as Power of Attorney (POA) or Authorized Representative (AOR) Forms.

By clicking Enroll Now, you will complete an Enrollment Application for Solis Health Plans.

Once you have successfully submitted the enrollment application, you will receive a communication from us advising if your application has been submitted. Once you have been approved by the Centers for Medicare and Medicaid (CMS), you’ll be enrolled in Solis Health Plans.

Let's review some of your personal details.

Permanent Address

Mail Address

Your Personal Contact

Emergency Contact

Language

Accessibility

Election Reason(s) Eligibility Check

Medicare Health Information

Your PCP Information

For Special Needs Plan (SNP) only

Long Term Care *

Other Insurance Coverage *

Paying your Plan Premium

Long Term Care *

Important: Read and Sign Below

Signature *

You are now leaving
Solis Health Plans

You will be redirected to

Enrollment

Before you start the Enrollment Application, please ensure you have the following documents:

Your Personal Contact Details.

Medicare ID Card: You must have Parts A and B to enroll in a Medicare Advantage plan.

Supporting Documents: Examples such as Power of Attorney (POA) or Authorized Representative (AOR) Forms.

By clicking Enroll Now, you will complete an Enrollment Application for Solis Health Plans.

Once you have successfully submitted the enrollment application, you will receive a communication from us advising if your application has been submitted. Once you have been approved by the Centers for Medicare and Medicaid (CMS), you’ll be enrolled in Solis Health Plans.

Let's review some of your personal details.

Permanent Address

Mail Address

Your Personal Contact

Emergency Contact

Language

Accessibility

Election Reason(s) Eligibility Check

Medicare Health Information

Your PCP Information

For Special Needs Plan (SNP) only

Long Term Care *

Other Insurance Coverage *

Paying your Plan Premium

Long Term Care *

Important: Read and Sign Below

Signature *

You are now leaving Solis Health Plans

You will be redirected to

You are now leaving
Solis Health Plans