Health First Health Plans Medicare Referral Form (2014)
Important Reminder: The prospective member must contact our Customer Service Department at (321) 434-5665 or (800) 716-7737 any day of the week with any questions or to request an enrollment form or in home appointment.
Per the Centers for Medicare & Medicaid Services (CMS) Health First Health Plans can not outreach to the prospective member.
*Prospective Member First Name:
A value is required.
*Prospective Member Last Name:
A value is required.
Date of Birth:
Address:
City:
State:
Zip:
Proposed effective date:
*Referring Associate or Broker/Realtor Name
(First and Last):
A value is required.
*Referring Broker/ Realtor License Number
OR
Associate Universal ID:
A value is required.
Referring Broker/ Realtor Agency Name
(if applicable):
*Please indicate referral source:
Friend, Family Member or Neighbor
Existing Client
Inbound telephone call
Retiring from existing group plan

Please make a selection.


* - indicates that the field is required.

 

Note for Brokers/Realtors: If we do not already have an PDF IRS W-9 form on file for you, please complete one and send it to us at HFHP_Medicare@Health-First.org.

Note: Referral must be submitted before the effective date of the member enrolling with Health First Health Plans, and member must enroll within three months of submitted referral.

**Disclaimer: Health First Physicians and Health First licensed sales associates are excluded from participating in this program. HFHP does not allow the sale of a Medicare Advantage product to a Medicare eligible by anyone other than an employed associate with an active Florida Health Insurance license, appointed with HFHP and who has successfully completed their AHIP certification. HFHP Medicare Sales Representatives are responsible for presenting the sale and assisting in the completion of the prospect's application for enrollment. The prospective member must be directed to contact our Customer Service Department at (321) 434-5665 or (800) 716-7737 to request an enrollment form, or in home appointment. Per the Centers for Medicare & Medicaid Services (CMS) HFHP cannot outreach to the prospective member. Customer Service business cards will be provided to each associate interested in participating in the referral program.

In accordance with our contract with CMS, HFHP has the right to monitor compliance through analysis of complaints or enrollee satisfaction surveys, rapid disenrollment surveys, and other sources of enrollee input. Health First has the right to exclude an associate from participation if results indicate HFHP is not appropriately represented. HF Associates who are also a HFHP MA or PDP member cannot participate and must be excluded per CMS Section 30.16 of Chapter 3.