Medicare Advance Care Plan Healthy Reward Form

Please complete the form below so we can process your Healthy Reward¹ for having an Advance Care Plan.

Your Information

Note: Asterisk * indicates a required field

Form

First Name*

Last Name*

Date of Birth*

Birth Month

Birth Day

Birth Year

Sentara Medicare Member ID*

Can be found on your ID card

Secondary Member ID*

Box 1: Enter the first 9 numbers before the asterisk * on your member ID card.

Box 2: Enter the last 2 numbers after the asterisk * on your member ID card.

Phone Number*

Email Address*

Do you have an Advance Care Plan?* Yes No

Have you reviewed your Advance Care Plan recently to make sure it still meets your needs?* Yes No

¹Medicare approved Sentara Medicare to provide some of these rewards as part of the Value-Based Insurance Design Program. This program lets Medicare try new ways to improve Medicare Advantage plans.

Rewards cannot be used to buy tobacco or alcohol. Rewards cannot be converted to cash. You can only receive one reward per applicable service per plan year. Rewards are not available to Sentara Medicare Savings (HMO) plan members.

© Sentara Health Plans 2024, 1300 Sentara Park, Virginia Beach, VA 23464

Sentara Health Plans is the trade name for Sentara Health Plans, Sentara Health Insurance Company, Sentara Health Administration, Inc., and Sentara Behavioral Health Services, Inc. Health Maintenance Organization (HMO) products, and Point-of-Service (POS) products are issued and underwritten by Sentara Health Plans. Preferred Provider Organization (PPO) products are issued and underwritten by Sentara Health Insurance Company. Sentara Health Administration, Inc. provides administrative services to group and individual health plans but does not underwrite benefits. All plans have benefit exclusions and limitations and terms under which the policy may be continued in force or discontinued. Medicare products are administered under an agreement with Sentara Health Plans and the Centers for Medicare and Medicaid Services (CMS). Medicaid and FAMIS products are administered under an agreement with Sentara Health Plans and the Virginia Department of Medical Assistance Services (DMAS).