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2019 Online Enrollment



  1. Go To Form
  2. Part 1
  3. Part 2
  4. Part 3
  5. Part 4
  6. Part 5

enrollment form


INSTRUCTIONS ON HOW TO ENROLL IN
PRIMETIME HEALTH PLAN


arrow pointing right YOU MUST LIVE IN THE PRIMETIME HEALTH PLAN SERVICE AREA, WHICH IS: arrow pointing left
CARROLL, COLUMBIANA, HARRISON, HOLMES, MAHONING, MEDINA,
PORTAGE, STARK, SUMMIT, TRUMBULL, TUSCARAWAS AND WAYNE COUNTIES


HAVE YOUR
MEDICARE CARD
AVAILABLE
You must have both
Medicare Part A
and Part B to enroll
in PrimeTime Health Plan.
1
SIGN AND DATE
THE
ENROLLMENT FORM
Your enrollment form is not
complete until you or your
authorized representative
have electronically signed and
dated the last page.
2
SUBMIT THE COMPLETED ENROLLMENT FORM TO RECEIVE YOUR CONFIRMATION NUMBER You will also receive a
Confirmation Letter once we
receive confirmation of your
enrollment from Centers for
Medicare and Medicaid Services (CMS).
3


You cannot have End-Stage Renal Disease at the time of enrollment,
unless you do not need regular dialysis or have had a successful kidney transplant.
(certain exceptions may apply)



WOULD YOU LIKE FURTHER INFORMATION ON WHICH
PRIMETIME HEALTH PLAN IS BEST FOR YOU?

Call us at the numbers listed below or attend one of our
informational meetings. Ask us for dates and times.



IF YOU NEED ASSISTANCE AT ANY TIME, PLEASE CONTACT PRIMETIME HEALTH PLAN
CUSTOMER SERVICE AT 330-363-7407 OR 1-800-577-5084 (TTY USERS SHOULD CALL 330-363-7460
OR 1-800-617-7446). OUR CALL CENTER IS OPEN MONDAY THROUGH FRIDAY FROM 8:00 a.m.
TO 8:00 p.m., E.S.T. (OCTOBER 1ST – MARCH 31ST, WE ARE AVAILABLE 7 DAYS A WEEK, 8:00 a.m.
TO 8:00 p.m., E.S.T.) OUR LOBBY IS OPEN MONDAY THROUGH FRIDAY 8:00 a.m. TO 4:30 p.m., E.S.T.


If you need information in another language or in an accessible format (like Braille, audiotape, or large print), please contact PrimeTime Health Plan at 330-363-7407 or 1-800-577-5084 (TTY users should call 330-363-7460 or 1-800-617-7446). Our Call Center is open Monday through Friday from 8:00 a.m. to 8:00 p.m., E.S.T. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m., E.S.T.) Our Lobby is open Monday through Friday from 8:00 a.m. to 4:30 p.m., E.S.T.