Medicare Enrollment Application
Congratulations, your application has been successfully submitted!
Now that you've enrolled, use this checklist to get started with your new plan.
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If you prefer us to send information in a language other than English or in an accessible format. Please contact BlueShield of Northeastern NY at the phone number listed below.
Call 1-833-735-4512 (TTY 711) if you have any questions.
October 1 - December 31 8 a.m. - 8 p.m., 7 days a week
January 1 - September 30 8 a.m. - 8 p.m., Monday - Friday
OMB No. 0938-1378
Privacy Act Statement
The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR §§ 422.50, 422.60, 423.30 and 423.32 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.
BlueShield of Northeastern New York (BSNENY) is a Medicare Advantage plan with a Medicare contract and enrollment depends on contract renewal. BSNENY is a division of HealthNow New York Inc., an independent licensee of the Blue Cross and Blue Shield Association. BSNENY complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-833-735-4515 (TTY 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-833-735-4515 (TTY 711)
Content last updated: February 3, 2021