Final Approval and Enrollment Clause Samples

Final Approval and Enrollment. If you decide to join LIFE, your LIFE Provider will ask you to sign this Enrollment Agreement. Upon signing this agreement, you will receive: • A copy of the signed Enrollment Agreement. • A sticker or a magnet with LIFE's emergency telephone numbers and an instruction sheet to put on or by your telephone telling you what to do in an emergency. • An identification card that must be used with your Medical Assistance and Medicare card indicating that you are enrolled in LIFE. Since LIFE provides comprehensive care for its participants, enrollment in LIFE results in disenrollment from any other Medicare or Medical Assistance plan. LIFE DISENROLLMENT‌ Your benefits under LIFE can be stopped if you choose to disenroll from the program voluntarily or if you no longer meet the conditions of enrollment and are involuntarily disenrolled. If you enroll into another Medicare plan, that will be considered a voluntary disenrollment from the LIFE Program. This program is available through an agreement LIFE has with the Department and CMS that is subject to renewal on a periodic basis. If this agreement is not renewed by those agencies, this program will be terminated.

Final Approval and Enrollment. If you decide to join LIFE, we will ask you to sign the Enrollment Agreement. Upon signing this agreement, you will receive: • A copy of the Enrollment Agreement. • A magnet with LIFE’s after hours number and emergency telephone number to post in your home. • A list of the health team members and LIFE contracted healthcare providers. • A temporary ▇▇▇▇▇ ▇▇▇▇▇▇▇ LIFE card that will identify you as a LIFE program participant until you receive your permanent new insurance card from LIFE. Your enrollment starts on the first day of the month after you sign the Enrollment Agreement. You will get a new Enrollment Agreement if any of the terms change after you enroll. All changes will be explained to you. You will have a chance to ask questions. Since LIFE provides comprehensive care for its participants, enrollment in LIFE results in disenrollment from any other Medicare or Medical Assistance prepayment plan or optional benefit. Electing enrollment in any other Medicare or Medicaid prepayment plan or optional benefit, including the hospice benefit, after enrolling as a LIFE participant is considered a voluntary disenrollment from LIFE. If a Medicaid-only or private pay participant becomes eligible for Medicare after enrollment in LIFE, the participant will be disenrolled from LIFE if he or she elects to obtain Medicare coverage other than from the participant’s LIFE organization. All LIFE services are provided and admissions and referrals are made without regard to race, sex, color, national origin, ancestry, religious creed, sexual orientation, or handicap. Complaints of discrimination may be filed with the following state agencies: A participant who becomes eligible for Medicare after enrollment must obtain all Medicare coverage (Parts A and/or B, and Part D) through Saint ▇▇▇▇▇▇▇ LIFE in order to remain in the PACE program. Saint ▇▇▇▇▇▇▇ LIFE will track your Medicare benefits to ensure that you are enrolled in the CMS Medicare systems as soon as possible. You will be notified by letter and/or a phone call and apprised of eligibility status and your options. You will be provided with a 60-day advance notice of your ability to opt out of PACE if you do not wish your Medicare services to be administered by the PACE program.

Final Approval and Enrollment. If you decide to join LIFE, we will ask you to sign the Enrollment Agreement. Upon signing this agreement, you will receive: A copy of the Enrollment Agreement. A sticker with LIFE's emergency telephone numbers and an instruction sheet to put on or by your telephone telling you what to do in an emergency. An identification card or sticker that must be placed with your Medical Assistance and Medicare card indicating that you are enrolled in LIFE. Since LIFE provides comprehensive care for its participants, enrollment in LIFE results in disenrollment from any other Medicare or Medical Assistance prepayment plan. All LIFE services are provided and admissions and referrals are made without regard to race, sex, color, national origin, ancestry, religious creed, sexual orientation, or handicap. Complaints of discrimination may be filed with the following state agencies: Office for Civil Rights Pennsylvania Human Relations Commission U.S. Department of Health & [go to ▇▇▇.▇▇▇▇.▇▇▇▇▇.▇▇.▇▇ for your local office] Human Services ▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇ Suite 372, Public Ledger Building Philadelphia, PA 19106-9111 Main Line (▇▇▇) ▇▇▇-▇▇▇▇ Hotline (▇▇▇) ▇▇▇-▇▇▇▇ Your benefits under LIFE can be stopped if you choose to disenroll from the program voluntarily or if you no longer meet the conditions of enrollment and are involuntarily disenrolled. This program is available through an agreement LIFE has with the state and federal government. If this agreement is not renewed by those agencies, this program will be terminated. The effective date of termination of benefits will be midnight of the last day of the month in which the notice was given.

Final Approval and Enrollment. If you found your visits to the Center to be satisfactory and if the IDT agrees that you are eligible, you and your family or significant other will meet with the Enrollment Specialist. During this meeting, you will review and come to an agreement about your participation in Trinity Health LIFE New Jersey. At this meeting, you will have an opportunity to discuss the following information: The Individual Plan of Care recommended for you by the IDT, which incorporates plans for family involvement. Review your monthly fee, if any (See Section X, 19 Monthly Fee). Your agreement to receive all health care services authorized and provided exclusively by Trinity Health LIFE New Jersey. Discuss what to do if you are unhappy with the care you receive at Trinity Health LIFE New Jersey (See Section XII, Grievance and Appeals); If you decide to join Trinity Health LIFE New Jersey, we will ask you to sign the Enrollment Agreement. Upon signing, you will receive the following information and documents: • A copy of the Enrollment Agreement • A magnet with Trinity Health LIFE New Jersey emergency telephone number to post in your home and a list of LIFE Staff and Contracted Providers with titles and phone numbers Trinity Health LIFE New Jersey is a voluntary health plan. You have the option of disenrolling from Trinity Health LIFE New Jersey should you choose. If you wish to disenroll, you can contact your Social Worker.

Final Approval and Enrollment. If you decide to join LIFE ▇▇▇▇▇▇▇▇▇ County, we will ask you to sign the Enrollment Agreement. Upon signing this agreement, you will receive: · A copy of the Enrollment Agreement. · A sticker with LIFE ▇▇▇▇▇▇▇▇▇ County's emergency telephone numbers and an instruction sheet to put on or by your telephone telling you what to do in an emergency. · An identification card or sticker must be placed with your Medical Assistance and Medicare card, indicating that you are enrolled in LIFE ▇▇▇▇▇▇▇▇▇ County. · Since LIFE ▇▇▇▇▇▇▇▇▇ County provides comprehensive care for its participants, enrollment in LIFE ▇▇▇▇▇▇▇▇▇ County results in disenrollment from any other Medicare or Medical Assistance prepayment plan. All LIFE ▇▇▇▇▇▇▇▇▇ County services are provided, and admissions and referrals are made without regard to race, sex, color, national origin, ancestry, religious creed, sexual orientation, or handicap. Complaints of discrimination may be filed with the following state agencies: U.S. Department of Health & ▇▇▇ ▇▇▇▇▇ ▇▇▇▇▇▇ Human Services Suite ▇▇▇, ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇ ▇. ▇▇▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇ ▇▇▇▇▇ ▇▇▇, Public Ledger Building ▇▇▇-▇▇▇-▇▇▇▇ Philadelphia, PA 19106-9111 412-565-5711 TTY users only Main Line: ▇▇▇-▇▇▇-▇▇▇▇ or visit the website: ▇▇▇.▇▇▇▇.▇▇▇▇▇.▇▇.▇▇ Hotline (▇▇▇) ▇▇▇-▇▇▇▇ Your benefits under LIFE ▇▇▇▇▇▇▇▇▇ County can be stopped if you choose to disenroll from the program voluntarily or if you no longer meet enrollment conditions and are involuntarily disenrolled. This program is available through an agreement LIFE ▇▇▇▇▇▇▇▇▇ County has with the state and the federal government. If those agencies do not renew this agreement, this program will be terminated. The effective date of termination of benefits will be midnight of the last day of the month in which the notice was given.

Final Approval and Enrollment. If you decide to join LIFE, we will ask you to sign the Enrollment Agreement. Upon signing this agreement, you will receive: • A copy of the Enrollment Agreement. • A sticker with LIFE's emergency telephone numbers and an instruction sheet to put on or by your telephone telling you what to do in an emergency. • An identification card or sticker that must be placed with your Medical Assistance and Medicare card indicating that you are enrolled in LIFE. Since LIFE provides comprehensive care for its participants, enrollment in LIFE results in disenrollment from any other Medicare or Medical Assistance prepayment plan.