Johns Hopkins Advantage MD (HMO, HMO D-SNP and PPO) Enrollment Request Form
Who can use this form?
People with Medicare who want to join a Medicare Advantage Plan
To join a plan, you must:
- Be a United States citizen or be lawfully present in the U.S.
- Live in the plan’s service area
Important: To join a Medicare Advantage Plan, you must also have both:
- Medicare Part A (Hospital Insurance)
- Medicare Part B (Medical Insurance)
When do I use this form?
You can join a plan:
- Between October 15–December 7 each year (for coverage starting January 1)
- Within 3 months of first getting Medicare
- In certain situations where you’re allowed to join or switch plans
Visit Medicare.gov to learn more about when you can sign up for a plan.
What do I need to complete this form?
- Your Medicare Number (the number on your red, white, and blue Medicare card)
- Your permanent address and phone number
Note: You must complete all items in Section 1. The items in Section 2 are optional — you can’t be denied coverage because you don’t fill them out.
- If you want to join a plan during fall open enrollment (October 15–December 7), the plan must get your completed form by December 7.
- Your plan will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.
What happens next?
Your completed form will be submitted to:
Johns Hopkins Advantage MD
P.O. Box 3538
Scranton, PA 18505
Once they process your request to join, they’ll contact you.
How do I get help from this form?
Call Johns Hopkins Advantage MD at 888-403-7662. TTY users can call 711.
En español: Llame a Johns Hopkins Advantage MD al 888-403-7662/TTY 711 o a Medicare gratis al 800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle 24 horas del día, los 7 días de la semana.
Individuals experiencing homelessness
If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., social security checks) may be considered your permanent residence address.
Medicare Compliance Department Contact Information
Johns Hopkins HealthCare has a Compliance Department Division dedicated to Johns Hopkins Advantage MD. You can reach the Medicare Compliance Department using the contact information listed below. Our hours of operation are Monday – Friday 8 a.m. – 5 p.m.
7231 Parkway Drive, Suite 100, Hanover, MD 21076
Attn: Medicare Compliance Department