Forms
Medicare Advantage HMO Plans
Tufts Medicare Preferred HMO member cards look like the samples below:
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Enrollment & Dis-Enrollment
HMO Dental Option Enrollment Form
This form is used to apply for enrollment in the Dominion Dental Option. The Dominion Dental Option is a rider benefit that must be added to, or purchased with, a Tufts Health Plan Medicare Preferred HMO plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health Plan Medicare Preferred HMO coverage.
Tufts Health Plan Medicare Preferred HMO Employer Group Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form
This form is used to disenroll from Tufts Health Plan Medicare Preferred plans. Please note that you must continue to get all medical care from Tufts Health Plan Medicare Preferred until the effective date of disenrollment.
Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
Tufts Medicare Preferred HMO Short Enrollment Form
This form allows current Tufts Health Plan Medicare Preferred members to request enrollment in a different Tufts Health Plan Medicare Preferred plan, in order to switch from one Tufts Health Plan Medicare Preferred plan to another, or add the Dental Option to a current Tufts Health Plan Medicare Preferred plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health Plan coverage.
Tufts Medicare Preferred Individual Enrollment Form
This form is used to apply for enrollment in a Tufts Health Plan Medicare Preferred plans. Please note, this form is intended for new enrollments. If you are a current member and need to switch your plan, please use the Tufts Health Plan Medicare Preferred plans Short Enrollment Form.
PPO Access Plan
Tufts Medicare PPO Access member cards look like the sample below:
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Tufts Health Plan Medicare Preferred HMO/PPO Disenrollment Form
This form is used to disenroll from Tufts Health Plan Medicare Preferred plans. Please note that you must continue to get all medical care from Tufts Health Plan Medicare Preferred until the effective date of disenrollment.
Tufts Health Plan Medicare Preferred Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
Tufts Medicare Preferred Individual Enrollment Form
This form is used to apply for enrollment in a Tufts Health Plan Medicare Preferred plans. Please note, this form is intended for new enrollments. If you are a current member and need to switch your plan, please use the Tufts Health Plan Medicare Preferred plans Short Enrollment Form.
Medicare Supplement Plans
Tufts Medicare Preferred Supplement member cards look like the sample below:
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Enrollment & Dis-Enrollment
Tuft Health Plan Medicare Supplement Dental Option Enrollment Form
This form is used to apply for enrollment in the Tufts Health Plan Medicare Supplement Dental Option. The Dental Option is a rider benefit that must be added to, or purchased with, a Tufts Health Plan Medicare Preferred Supplement plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health Plan Medicare Preferred Supplement coverage.
Tufts Health Plan Medicare Preferred Supplement Enrollment Application
This form is used to enroll in a Tufts Health Plan Medicare Preferred Supplement plan.
Tufts Health Plan Senior Care Options (D-SNP)
Tufts Health Plan Senior Care Options member cards look like the samples below:
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Tufts Health Plan Senior Care Options (D-SNP) Short Enrollment Form
This form allows current Tufts Health Plan Senior Care Options (D-SNP) members to request enrollment in a different Tufts Health Plan Senior Care Options (D-SNP) plan, in order to switch from one Tufts Health Plan Senior Care Options (D-SNP) plan to another, or add the Dental Option to a current Tufts Health Plan Senior Care Options (D-SNP) plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health Plan Senior Care Options (D-SNP) plan coverage.
Tufts Health Plan Senior Care Options (D-SNP) Disenrollment Form
This form is used to disenroll from Tufts Health Plan Senior Care Options plan. Please note that you must continue to get all medical care from Tufts Health Plan Medicare Preferred until the effective date of disenrollment.
Tufts Health Plan Senior Care Options (D-SNP) Enrollment Form
This form is used to apply for enrollment in the Tufts Health Plan Senior Care Options (HMO-SNP) plan.
Tufts Health Plan Senior Care Options (D-SNP) Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.
Tufts Health One Care (D-SNP)
Tufts Health One Care member cards look like the samples below:
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Enrollment & Dis-Enrollment
Tufts Health One Care (D-SNP) Short Enrollment Form
This form allows current Tufts Health One Care (D-SNP) members to request enrollment in a different Tufts Health One Care (D-SNP) plan, in order to switch from one Tufts Health One Care (D-SNP) plan to another, or add the Dental Option to a current Tufts Health One Care (D-SNP) plan. Please note, there may be enrollment restrictions depending on when you originally enrolled in your Tufts Health One Care (D-SNP) plan coverage.
Tufts Health One Care (D-SNP) Disenrollment Form
This form is used to disenroll from the Tufts Health One Care plan. Please note that you must continue to get all medical care from Tufts Health Plan until the effective date of disenrollment.
Tufts Health One Care (D-SNP) Enrollment Decision Form
The One Care Enrollment Decision Form asks you to make a decision about whether you want to get your MassHealth and Medicare coverage through a One Care plan. You have the right to ask questions before deciding if One Care is right for you. View this form for more information.
Tufts Health One Care (D-SNP) Enrollment Form
This form is used to apply for enrollment in the Tufts Health One Care (D-SNP) plan.
Tufts Health One Care (D-SNP) Pre Enrollment Checklist
This form helps you better understand the enrollment process, plan benefits and plan rules before enrolling.