You selected Devoted GIVEBACK Arizona (HMO) for 2024.
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.