Viva Design System

Name & Contact Info

Please complete the form below to start the enrollment process.

Please Note: Don't enter a PO Box. However for individuals experiencing homelessness, a PO Box may be considered your permanent residence address.

Title

First Name *

Middle Initial

Last Name *

Gender *

Applicant Date of Birth *

Email *

Phone Number *

Cell Phone *

Permanent Street Address

Street Address *

Suite, apt, etc.

City *

State *

Zip Code + 4 Digits *

Country *

The county you live in will determine the Viva Medicare plans available to you. The +4 on your zip code helps Viva Medicare determine the county because zip codes can fall in two or even three counties. These 4 digits can be found on your driver's license.

Mailing Address

My Mailing Address is the same as my Permanent Address.

Website Privacy Notice

Please review Viva Health's Website Privacy Notice to continue enrolling in a plan:

STOP - Please Read

This privacy notice discloses the privacy practices for www.vivahealth.com regarding information we collect from our website users. This privacy notice applies solely to information collected by this website.

Information Collection, Use, and Sharing
Viva Health is the sole owner of the information collected on this site. We have access to information that you voluntarily give us via email or other direct contact from you. We will not sell or rent this information to anyone. We will use your information to respond to you regarding the reason you contacted us and/or to process your on-line enrollment application. We will not share any information you submit to us via the website with any third party outside of our organization unless the disclosure is permitted by law.

I agree *

By clicking "I Agree" you acknowledge you have reviewed and accept Viva Health's Website Privacy Notice

Contact Notice

I agree that Viva Health may contact me regarding this application.

Cancel Enrollment

Please provide your Medicare health insurance information below. Reference your Medicare card to complete this section. You must have Medicare Part A and Part B to join a Medicare Advantage Plan.

If you do not have your Medicare card or your card is not accessible, please call 1-800-Medicare or visit www.ssa.gov. Be sure to ask for your Medicare number and Parts A & B effective dates.

Your Medicare Number *

I have confirmed that my Medicare number is correct. *

Medicaid Info

Please answer the following questions regarding your additional healthcare information. Some individuals may have other health care coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, or VA benefits.

If you do not have your Medicaid Number, please call the Alabama State Medicaid office at 1-800-362-1504. Be sure to ask for your Medicaid Number and your State Enrolled Medicaid program type.

Are you enrolled in your State Medicaid program?

Yes

No

Cancel Enrollment

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Viva Medicare Online Eligibility Questions

Typically, you may enroll in a Medicare advantage plan only during the annual enrollment period from October 15 through December 7th of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box of the statement that best applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

I am new to Medicare:

I am making my annual election of enrollment (Oct. 15th - Dec. 7th).

I am new to both Medicare Parts A & B

I am new to Medicare Part B only.

I have Medicare, but something has changed:

I had Medicare due to disability, but am turning 65.

I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).

I recently moved outside of the service area for my current plan, or I recently moved and this plan is a new option for me.

I moved on: *

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long term care facility).

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

I recently left a PACE program.

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change in the level of Extra Help, or lost Extra Help) on:

I was enrolled in a plan by Medicare (for my state) and I want to choose a different plan.

I was enrolled in a Special Needs Plan (SNP) but I have lost my special needs qualification required to be in that plan.

I had the following life event:

I recently was released from incarceration.

I recently returned to the United States after living permanently outside of the U.S.

I recently obtained lawful presence status in the United States.

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid) on:

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven't had a change.

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicar's).

I am leaving employer or union coverage.

I belong to a pharmacy assistance program provided by my state,

I was affected by a weather-related emergency or major disaster (as declared by the Federal Emergency Management Agency (FEMA)). One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

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Compare & Choose Your Viva Medicare Plan

If you would like to receive more information about our plans or if you need help enrolling, please call 1-888-830-8482. TTY users call the Alabama Relay Service at 711.

Premium:

^$0_/mo

PCP:

^$0

Specialist:

^$25

Part D Details:

Generic drugs starting at $0; $300 deductible for Tier 3, Tier 4, and Tier 5 drugs (the deductible does not apply to Tier 1 and Tier 2 drugs); $0 for generic and brand name drugs in the Catastrophic Phase.

Premium:

^$103_/mo

PCP:

^$0

Specialist:

^$20

Part D Details:

Generic drugs starting at $0; $100 deductible for Tier 3, Tier 4, and Tier 5 drugs (the deductible does not apply to Tier 1 and Tier 2 drugs); $0 for generic and brand name drugs in the Catastrophic Phase.

Premium:

^$0_/mo

PCP:

^$0

Specialist:

^$35

Part D Details:

None

Premium:

^$0_/mo

PCP:

^$0

Specialist:

^$0 - ^$12

Part D Details:

None

Social Security Information

You have selected Viva Medicare Extra Value as your plan. Please provide your Social Security Number below.

Your Social Security Number

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Additional Drug Coverage

Some individuals may have other drug coverage including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.

Will you have other prescription drug coverage in addition to Viva Medicare? *

Yes

No

Optional Information

Answering all of the questions below is your choice. You can't be denied coverage because you didn't fill them out.

Primary Care Physician (PCP), Clinic, or Health Center Information

Your PCP, Clinic or Health Center Info

PCP Email Address

Employment Info

Do you work?

Yes

No

Prefer not to answer

Does your spouse work?

Yes

No

Prefer not to answer

Accessibility

Yes, please send information in large print format

Yes, please information in audio CD format

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Payment Method

You can pay your monthly plan premium, including any late enrollment penalty that you currently have or may owe, by mail or by Electronic Funds Transfer (EFT) from your bank each month. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part-D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON'T pay Viva Medicare the Part D-IRMAA.

Please note: if you don't select a payment option, you will get a bill each month.

Which premium payment option would you like?

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check.

Electronic funds transfer (EFT) from your bank account each month.

Get a bill each month (Default Option)

You will be responsible for postage to mail your payment.

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Did someone else help enrollee complete this form?

No, I filled this out myself.

Yes, I have assisted the enrollee in completing this form.

Yes, I am a legal representative to the enrollee.

First Name *

Last Name *

Relationship to Enrollee *

Authorized Representative

First Name *

Last Name *

Address *

Email *

Phone number *

Relationship to Enrollee *

I attest that I have the authority to make this enrollment request and proof of this authority may be requested at any time by Viva Medicare. *

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Confirmation

Please read the following carefully:

By completing this enrollment application, you agree to the following:

I must keep both Hospital (Part A) and Medical (Part B) to stay in Viva Medicare.
By joining this Medicare Advantage Plan or Medicare Prescription Drug Plan, I acknowledge that Viva Medicare 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.
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 Viva Medicare coverage begins, I must get all of my medical and prescription drug benefits from Viva Medicare Benefits and services provided by Viva Medicare and contained in my Viva Medicare “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Viva Medicare 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:
This person is authorized under State law to complete this enrollment, and
Documentation of this authority is available upon request by Medicare.

Electronic Communication: I consent to be contacted by Viva Medicare, or its business associates, for certain health care communications at the phone number (cellular or landline) and email address above (including voice messages made by an auto-dialer or pre-recorded voice and text messages sent to my cellular number). I understand that my phone or internet carrier may charge fees for these communications (I may contact my carrier for pricing plans and details).

I understand that Viva Medicare has policies and procedures in place to safeguard my personal health information; however, there are some data security and privacy risks associated with sending and receiving communications about my health care. Communications I send or receive may not be sent and stored securely and may be accessed by third parties. I understand that I may cancel this consent (revoke or opt-out) by contacting Viva Medicare Member Services.

Cancel Enrollment

Previous Submit Application

Medicare Advantage Plan Enrollment

1 Applicant info

2 Eligibility

3 Choose Your Plan

4 Completing Enrollment

Need help?

Speak with a Rep Now

Name & Contact Info

Permanent Street Address

Mailing Address

Website Privacy Notice

Contact Notice

Medicare Info

Medicaid Info

Viva Medicare Online Eligibility Questions

Compare & Choose Your Viva Medicare Plan

Part D Details:

Part D Details:

Part D Details:

Medicaid Required

Part D Details:

Social Security Information

Additional Drug Coverage

Optional Information

Primary Care Physician (PCP), Clinic, or Health Center Information

Employment Info

Accessibility

Payment Method

Which premium payment option would you like?

Did someone else help enrollee complete this form?

Authorized Representative

Confirmation

Need help?

Speak with a Rep Now