You selected Devoted GIVEBACK Ohio (HMO) for 2024.

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Who can use this form?

People with Medicare who want to join a Medicare Advantage plan.
If you're working with a sales agent, you don't need to use this form. Work with them to finalize your application.

To join a plan, you must:

Be a United States citizen or be lawfully present in the U.S.
Live in the plan's service area

IMPORTANT: To join a Medicare Advantage Plan, you must also have both:

Medicare Part A (Hospital Insurance)
Medicare Part B (Medical Insurance)

When do I use this form?

You can join a plan:

Between October 15-December 7 each year (for coverage starting January 1)
Within 3 months of first getting Medicare
In certain situations where you're allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

Your Medicare Number (the number on your red, white, and blue Medicare card)
Your permanent address and phone number

Note: You must complete all items in Step 1 (Personal). The items in Step 3 (Options) are optional — you can't be denied coverage because you don't fill them out.

What happens next?

Once we process your request to join, we'll contact you.

Reminders

If you want to join a plan during fall open enrollment (October 15-December 7), the plan must get your completed form by December 7.
Your plan will send you a bill for the plan's premium. You can choose to sign up to have your premium payments deducted from your monthly Social Security (or Railroad Retirement Board) benefit.

How do I get help with this form?

Call Devoted Health at 1-800-990-0723 (TTY 711). Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

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