1. Personal
  2. Other Coverage
  3. Options
  4. Sign & Review

1 of 4 Personal

First, tell us a bit more about yourself.

Birth Date (*Required)
Sex (*Required)

To get text messages from Devoted, provide your cell phone number below.*

Would you like to get most plan communications electronically, on our secure member portal? This includes CMS-required documents like the Annual Notice of Changes (ANOC) or Explanation of Benefits (EOB). If YES: We’ll email or text you when there’s a new communication. You can opt-out of electronic delivery at any time. If we don’t have your email or cell number, you’ll keep getting paper documents.

Permanent Residence Street Address

Don’t enter a PO Box. Note: For individuals experiencing homelessness, a PO Box may be considered your permanent residence address.

Your Medicare Information


*By providing my cell phone number, I consent to receiving text messages regarding my plan and care from Devoted Health and its related medical practices. Msg frequency varies. Msg & data rates may apply. Reply STOP to cancel messages and HELP for help. devoted.com/terms-of-use and devoted.com/privacy-policy

Answering these questions is your choice.

You can't be denied coverage because you don't fill them out.

Are you Hispanic, Latino/a, or Spanish origin? Select all that apply.

What's your race? Select all that apply.

What is your gender? Select one.
Which of the following best represents how you think of yourself? Select one.

Let's check if you can join a plan right now.

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.

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 on (*Required)
I was released on (*Required)
I returned to the U.S. on (*Required)
I got this status on (*Required)
My Medicaid status changed on (*Required)
My Extra Help changed on (*Required)
I moved/will move into/out of the facility on (*Required)
I left on (*Required)
I lost my drug coverage on (*Required)
I am leaving on (*Required)
My enrollment in that plan started on (*Required)
I was disenrolled from the SNP on (*Required)

If none of these statements applies to you or you’re not sure, please contact Devoted Health at 1-800-990-0723 (TTY 711) to see if you are eligible to enroll. We are open 8am to 8pm, Monday to Friday (from October 1 to March 31, 8am to 8pm, 7 days a week).

Answer These Important Questions

Are you a Veteran?
Do you currently or will you have other prescription drug coverage (like VA, TRICARE) in addition to your Devoted Health plan? (*Required)
Start date of coverage (*Required)
End date of coverage (*Required)
Are you enrolled in your state Medicaid program? (*Required)

Fill out this section to help us better serve you.

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Please contact Devoted Health at 1-800-990-0723 (TTY 711) if you need information in an accessible format other than what’s listed above. We are open 8am to 8pm, Monday to Friday (from October 1 to March 31, 8am to 8pm, 7 days a week).

Do you work?
If you're married, does your spouse work?

Tell us about your primary care provider (PCP)

Your PCP is the main doctor you see for your care. Please tell us who you want to be your PCP. HMO members: If you leave this section blank or list an out-of-network provider, we’ll choose a PCP for you.

Paying Your Plan Premiums

If your plan has a monthly premium (including any late enrollment penalty you may owe), you can pay it by mail each month, or with a credit or debit card on our secure online portal. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T pay Devoted Health the Part D-IRMAA.

How would you like to pay? Only choose one. If you don’t select an option below, we’ll send a monthly bill.

*It may take at least 2 months for your premium to start coming out of your check. If you choose this option, you may still need to pay Devoted directly for the first few months.

IMPORTANT: Read and Sign Below

  • I must keep both Hospital (Part A) and Medical (Part B) to stay in Devoted Health
  • By joining this Medicare Advantage, I acknowledge that Devoted Health 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).
  • My 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 Devoted Health coverage begins, I must get all of my medical (and prescription drug benefits, if applicable) from Devoted Health. Benefits and services provided by Devoted Health and contained in my Devoted Health “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Devoted Health will pay for benefits or services that are not covered.
  • If enrolling in a SNP: By joining this plan, I confirm that I meet the eligibility criteria.
  • 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:
    • This person is authorized under State law to complete this enrollment, and
    • Documentation of this authority is available upon request by Medicare.
Please tell us who you are. (*Required)

Authorized Representative

Please fill in the information below. The Enrollee is the person you're helping sign up for this plan.

Address