• I must keep both Hospital (Part A) and Medical (Part B) to stay in Lagniappe Advantage.
• By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that
Lagniappe Advantage will share my information with Medicare, who may use it to track my enrollment,
to make payments, and for other purposes allowed by Federal law that authorize the collection of this
information (see Privacy Act Statement below). Your response to this form is voluntary. However, failure
to respond may affect enrollment in the plan.
• I understand that I can be enrolled in only one MA plan at a time – and that enrollment in this plan will
automatically end my enrollment in another MA plan (exceptions apply for MA PFFS, MA MSA plans).
• The information on this enrollment form is correct to the best of my knowledge. I understand that if I
intentionally provide false information on this form, I will be disenrolled from the plan.
• I understand that people with Medicare are generally not covered under Medicare while out of the
country, except for limited coverage near the U.S. border.
• I understand that when my Lagniappe Advantage coverage begins, I must get all of my medical and
prescription drug benefits from Lagniappe Advantage. Benefits and services provided by Lagniappe
Advantage and contained in my Lagniappe Advantage “Evidence of Coverage” document (also known as a
member contract or subscriber agreement) will be covered. Neither Medicare nor Lagniappe Advantage
will pay for benefits or services that are not covered.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on
this application means that I have read and understand the contents of this application. If signed by an
authorized representative (as described above), this signature certifies that:
1) This person is authorized under State law to complete this enrollment, and
2) Documentation of this authority is available upon request by Medicare.