Y0066_EOC_H5322_031_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of CoveragePlan Name Effective Year Benefit Package Summary; H5322-031 - UnitedHealthcare Dual Complete LP (HMO D-SNP) 2023: H5322-031: Download: AARP Medicare Advantage Plan 1 (HMO-POS)UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 - UL4 Social Security Number (Required for people who are enrolling in D-SNP plans): _ _ Medicare Number Permanent Residence Street Address (P.O. Box is not allowed) City County State ZIP Code Mailing Address (Only if it’s different from above. You can give a P.O. Box.) CityTTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the UnitedHealthcare Dual Complete (HMO-POS D-SNP) benefit details. — Medicare Plan Features —. Monthly Premium: $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) Annual Deductible: 2022 Medicare Part D Browse a Plan Formulary (Drug List) - Providing detailed information on the Medicare Part D program for every state, including selected Medicare Part D plan features and costs organized by State. 2022 UnitedHealthcare Dual Complete LP (HMO D-SNP) - H5322-031-0 in OK Star Rating DetailsLearn more about the UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5322-030-000 plan for Georgia. Check eligibility, explore benefits, and enroll today. 2022 Summary of Benefits GNHH4HIEN_22_C H5216228000SB22 SBOSB035 HumanaChoice SNP-DE H5216-228 (PPO D-SNP) Oklahoma Select Counties in Oklahoma The table below outlines some of the specific plan details for UnitedHealthcare Medicare Advantage plans available in Oklahoma in 2023. Plan Name. Plan Code. Monthly Premium. Deductible. Out of. Pocket Max. Prescription Drug Coverage. Medicare. Quick reference guide 2022 UnitedHealthcare Care Provider Administrative Guide iii Contact UnitedHealthcare Most questions can be answered using our online solutions at uhcprovider.com.2022 UnitedHealthcare Dual Complete LP (HMO D-SNP) - H5322-031-0 in OK Star Rating Details Plan Name Effective Year Benefit Package Summary; H5322-031 - UnitedHealthcare Dual Complete LP (HMO D-SNP) 2023: H5322-031: Download: AARP Medicare Advantage Plan 1 (HMO-POS)¿Qué es una Lista de Medicamentos? Una Lista de Medicamentos, o Formulario, es una lista de los medicamentos con receta que cubre su plan. Su plan y un equipo de proveedores de cuidado de la salud colaboran en la selección de Sep 26, 2022 · H5322-031-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5322_031_000_2023_M 2022 Medicare Advantage Plan Details. Medicare Plan Name: UnitedHealthcare Dual Complete LP (HMO D-SNP) Location: Tillman, Oklahoma Click to see other locations. Plan ID: H5322 - 031 - 0 Click to see other plans. Member Services: 1-844-368-7150 TTY users 711.UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) 5 out of 5 stars* for plan year 2023. UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) is a HMO-POS D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.Provider Directory 2023 UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Oklahoma Adair, Bryan, Carter, Cherokee, Delaware, Grady, Le Flore, Muskogee, Osage ...Vendor Information UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Take advantage of your additional plan benefits by using the providers below or contacting2019 UnitedHealthcare Dual Complete (HMO SNP) - H5322-031-0 in OK Plan Benefits ExplainedProvider Directory 2023 UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Oklahoma Alfalfa, Atoka, Beaver, Beckham, Blaine, Caddo, Choctaw, Cimarron, Coal, Comanche ...H5322-031 OK99OKDSNPF OK99OKDSNPP OK99OKDSNPQ UnitedHealthcare Dual ... H5322-033 OK99OKDSNP4F, OK99OKDSNP4P, OK99OKDSNP4Q. 2022 United HealthCare Services Inc. All ... UnitedHealthcare offers UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 plans for Oklahoma and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll.Learn more about the UnitedHealthcare Dual Complete® (HMO-POS D-SNP) H5322-030-000 plan for Georgia. Check eligibility, explore benefits, and enroll today.UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) 5 out of 5 stars* for plan year 2023. UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) is a HMO-POS D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.Guía de Inscripción 2023 Aproveche todo lo que su plan Medicare Advantage tiene para ofrecer UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 Área de servicio: Oklahoma - condados de Adair, Alfalfa, Atoka, Beaver, Beckham, Blaine, Bryan,o UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 - UL4 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ FemeninoY0066_ANOC_H5322_031_000_2023_M. Y0066_210610_INDOI_C Find updates to your plan for next year This notice provides information about updates to your plan, but it ... Y0066_ANOC_H5322_031_000_2023_M. Y0066_210610_INDOI_C Find updates to your plan for next year This notice provides information about updates to your plan, but it ... 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H5322-031-000; 2023 UnitedHealthcare Dual Complete Plan Frequently Asked Questions H5322-033-000; 2023 UnitedHealthcare Dual Complete Plan Quick Reference Guide for Oklahoma; 2022 Plan Resource Materials. 2022 UnitedHealthcare Dual Complete® Plan Frequently Asked Questions ... UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) 5 out of 5 stars. UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare. Plan ID: H5322-031. $ 0.00.We would like to show you a description here but the site won’t allow us.Cigna Alliance Medicare (HMO) H3949-031 1 Summary of Benefits H3949_23_791509_M Better benefits supported by a dedicated network of providers with no referrals required To Join You must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Service Area Bucks, Chester, Delaware, Montgomery, and Philadelphia 2023 Evidence of Coverage for UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Table of Contents Questions? Call Customer Service at 1-866-842-4968, TTY 711, 8am-8pm: 7 Days Oct-TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the Medicare Plus Blue PPO Signature (PPO) benefit details. — Medicare Plan Features —. Monthly Premium: $150.00. Annual Deductible: $0. Annual Initial Coverage Limit (ICL): 2019 Medicare Advantage Plan Benefit Details for the UnitedHealthcare Dual Complete (HMO SNP) - H5322-031-0 This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans. Plan Name Effective Year Benefit Package Summary; H5322-031 - UnitedHealthcare Dual Complete LP (HMO D-SNP) 2023: H5322-031: Download: AARP Medicare Advantage Plan 1 (HMO-POS)UnitedHealthcare - H5322 For 2023, UnitedHealthcare - H5322 received the following Star Ratings from Medicare: Overall Star Rating: 5 stars Health Services Rating: 5 stars Drug Services Rating: 4.5 stars Every year, Medicare evaluates plans based on a 5-star rating system. Why Star Ratings are Important Medicare rates plans on their health and ... Quick reference guide 2022 UnitedHealthcare Care Provider Administrative Guide iii Contact UnitedHealthcare Most questions can be answered using our online solutions at uhcprovider.com. Y0066_ANOC_H5322_031_000_2023_SP_M. Y0066_210610_INDOI_C Encuentre las actualizaciones de su plan para el próximo añoH5322-031-000, H0271-053-000, H5322-033-000. 2 Table of contents UnitedHealthcare hospice VBID model overview ...Number of Members enrolled in this plan in (H5322 - 031): 5,075 members : Plan’s Summary Star Rating: 4 out of 5 Stars. • Customer Service Rating: 5 out of 5 Stars. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split as Follows: : Total ... UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) 5 out of 5 stars* for plan year 2023. UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) is a HMO-POS D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.o UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 - UL4 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ Femenino Y0066_EOC_H5322_031_000_2023_SP_C. OMB Approval 0938-1051 (Expires: February 29, 2024) Del 1 de enero al 31 de diciembre de 2023 Evidencia de Cobertura Introduction facility that is currently Medicare-approved for your specific type of transplant. The plan’s hospital network for organ transplant services is different than the network shown in the “Hospitals” section 2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5322-031-000 Subject UnitedHealthcare Dual Complete additional benefit overview for health care professionals. UnitedHealthcare offers UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 plans for Oklahoma and eligible counties. This plan gives you a choice of doctors and hospitals. Learn about steps to enroll.Maximum 3 visits every year. Copayment for Fluoride Treatment $0.00. Maximum 2 visits every year. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $3500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined.2023 UnitedHealthcare Dual Complete Plan Benefit Flyer H5322-031-000 Subject UnitedHealthcare Dual Complete additional benefit overview for health care professionals. o UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 - UL4 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ FemeninoProvider Directory 2023 UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Oklahoma Canadian, Cleveland, Kingfisher, Lincoln, Logan and Oklahoma Counties Enrollment Guide 2023 Take advantage of all your Medicare Advantage plan has to offer UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 Service area: Oklahoma - Adair, Alfalfa, Atoka, Beaver, Beckham, Blaine, Bryan, Caddo, Canadian,729 Medicare Advantage Plans from Humana. Coverage varies by plan. Select a Medicare Advantage Plan below to view details about the coverage it provides: Plan CodePlan Name. H0028:007-0 Humana Gold Plus SNP-DE H0028-007 (HMO D-SNP) H0028:014-0 Humana Gold Plus H0028-014 (HMO) H0028:015-0 Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) H0028 ...2023 Evidence of Coverage for UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Table of Contents Questions? Call Customer Service at 1-866-842-4968, TTY 711, 8am-8pm: 7 Days Oct- Y0066_EOC_H5322_031_000_2023_SP_C. OMB Approval 0938-1051 (Expires: February 29, 2024) Del 1 de enero al 31 de diciembre de 2023 Evidencia de CoberturaProvider Directory 2023 UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Oklahoma Alfalfa, Atoka, Beaver, Beckham, Blaine, Caddo, Choctaw, Cimarron, Coal, Comanche ... Cigna Alliance Medicare (HMO) H3949-031 1 Summary of Benefits H3949_23_791509_M Better benefits supported by a dedicated network of providers with no referrals required To Join You must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Service Area Bucks, Chester, Delaware, Montgomery, and Philadelphia729 Medicare Advantage Plans from Humana. Coverage varies by plan. Select a Medicare Advantage Plan below to view details about the coverage it provides: Plan CodePlan Name. H0028:007-0 Humana Gold Plus SNP-DE H0028-007 (HMO D-SNP) H0028:014-0 Humana Gold Plus H0028-014 (HMO) H0028:015-0 Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) H0028 ...2022 UnitedHealthcare Dual Complete LP (HMO D-SNP) - H5322-031-0 in OK Star Rating DetailsIntroduction If you have a medical emergency, get help as quickly as possible. Call 911 or go to the nearest emergency room or hospital. Emergency care can always be obtained in or out of the service areaPlan Name Effective Year Benefit Package Summary; H5322-031 - UnitedHealthcare Dual Complete LP (HMO D-SNP) 2023: H5322-031: Download: AARP Medicare Advantage Plan 1 (HMO-POS)UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) 5 out of 5 stars* for plan year 2023. UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) is a HMO-POS D-SNP Medicare Advantage (Medicare Part C) plan offered by UnitedHealthcare.UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) UnitedHealthcare Dual Complete® Select (HMO-POS D-SNP) Complete Drug List (Formulary) 2023 Important notes: This document has information about the drugs covered by this plan.2019 UnitedHealthcare Dual Complete (HMO SNP) - H5322-031-0 in OK Plan Benefits Explained H5322-031-000 Consulte esta guía y aproveche las coberturas de medicamentos y los servicios de salud que proporciona el plan. Llame a Servicio al Cliente o visite el sitio web para obtener más información sobre el plan. Llamada gratuita 1-844-560-4944, TTY 711 8 a.m. a 8 p.m., hora local, los 7 días de la semana UHCCommunityPlan.comWe would like to show you a description here but the site won’t allow us.o UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 - UL4 Datos del miembro (escriba a máquina o en letra de molde con tinta negra o azul) Apellidos Nombre Inicial del segundo nombre Fecha de nacimiento Sexo ¨ Masculino ¨ FemeninoY0066_EOC_H5322_031_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of CoverageY0066_EOC_H5322_031_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage Y0066_ANOC_H5322_031_000_2023_SP_M. Y0066_210610_INDOI_C Encuentre las actualizaciones de su plan para el próximo año H5322-031-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5322_031_000_2023_M Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00. Prior Authorization Required for Doctor Specialty Visit. Inpatient hospital care. In-Network: Acute Hospital Services: $0.00 per day for days 1 to 6. $0.00 per day for days 7 to 90. Prior Authorization Required for Acute Hospital Services. Number of Members enrolled in this plan in (H5322 - 030): 3,347 members : Plan’s Summary Star Rating: 3.5 out of 5 Stars. • Customer Service Rating: Insufficient data to rate this plan. • Member Experience Rating: 4 out of 5 Stars. • Drug Cost Accuracy Rating: 4 out of 5 Stars. — Plan Premium Details — The Monthly Premium is Split ...Maximum 3 visits every year. Copayment for Fluoride Treatment $0.00. Maximum 2 visits every year. Copayment for Dental X-Rays $0.00. Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $3500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined. 2022 UnitedHealthcare Dual Complete LP (HMO D-SNP) - H5322-031-0 in OK Star Rating Details The UnitedHealthcare Dual Complete LP (HMO D-SNP) (H5322 - 031) currently has 23,586 members. There are 114 members enrolled in this plan in Craig, Oklahoma, and 23,493 members in Oklahoma. The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4.5 stars. Resources and tools for providers and health care ...TTY users 1-877-486-2048. or contact your local SHIP for assistance. Email a copy of the Medicare Plus Blue PPO Signature (PPO) benefit details. — Medicare Plan Features —. Monthly Premium: $150.00. Annual Deductible: $0. Annual Initial Coverage Limit (ICL):2022 Summary of Benefits GNHH4HIEN_22_C H5216228000SB22 SBOSB035 HumanaChoice SNP-DE H5216-228 (PPO D-SNP) Oklahoma Select Counties in Oklahoma Catastrophic drug coverage limit. $7,400.00. Primary care doctor visit. $0 in-network / $55 out-of-network. Specialty doctor visit. $35 in-network / $60 out-of-network. Inpatient hospital care. $375 per day, days 1-5; $0 per day, days 6-90 in-network / 50% per stay out-of-network. Urgent care. You are now accessing JARVIS as: {{loggedInUserName}}, (PID: {{loggedInUserPartyId}}) (WID: {{loggedInUserAgentId}}) Provider Directory 2023 UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Oklahoma Adair, Bryan, Carter, Cherokee, Delaware, Grady, Le Flore, Muskogee, Osage ...2019 UnitedHealthcare Dual Complete (HMO SNP) - H5322-031-0 in OK Plan Benefits Explained H5322-031-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5322_031_000_2023_M2022 Summary of Benefits GNHH4HIEN_22_C H5216228000SB22 SBOSB035 HumanaChoice SNP-DE H5216-228 (PPO D-SNP) Oklahoma Select Counties in OklahomaIntroduction Introduction This directory provides a list of the plan’s network providers. Depending on your plan, you may receive certain covered services from out-of-network providers that participate in Medicare andH5322-031 OK99OKDSNPF OK99OKDSNPP OK99OKDSNPQ UnitedHealthcare Dual ... H5322-033 OK99OKDSNP4F, OK99OKDSNP4P, OK99OKDSNP4Q. 2022 United HealthCare Services Inc. All ... H5322-031-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5322_031_000_2023_M H5322-031-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5322_031_000_2023_Mo UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 - UL4 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number ¿Qué es una Lista de Medicamentos? Una Lista de Medicamentos, o Formulario, es una lista de los medicamentos con receta que cubre su plan. Su plan y un equipo de proveedores de cuidado de la salud colaboran en la selección de
The table below outlines some of the specific plan details for UnitedHealthcare Medicare Advantage plans available in Oklahoma in 2023. Plan Name. Plan Code. Monthly Premium. Deductible. Out of. Pocket Max. Prescription Drug Coverage. Medicare.. My fatherpercent27s dragon reading level
729 Medicare Advantage Plans from Humana. Coverage varies by plan. Select a Medicare Advantage Plan below to view details about the coverage it provides: Plan CodePlan Name. H0028:007-0 Humana Gold Plus SNP-DE H0028-007 (HMO D-SNP) H0028:014-0 Humana Gold Plus H0028-014 (HMO) H0028:015-0 Humana Gold Plus SNP-DE H0028-015 (HMO-POS D-SNP) H0028 ...Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00. Prior Authorization Required for Doctor Specialty Visit. Inpatient hospital care. In-Network: Acute Hospital Services: $0.00 per day for days 1 to 6. $0.00 per day for days 7 to 90. Prior Authorization Required for Acute Hospital Services.Y0066_ANOC_H5322_031_000_2023_SP_M. Y0066_210610_INDOI_C Encuentre las actualizaciones de su plan para el próximo año Catastrophic drug coverage limit. $7,400.00. Primary care doctor visit. $0 in-network / $55 out-of-network. Specialty doctor visit. $35 in-network / $60 out-of-network. Inpatient hospital care. $375 per day, days 1-5; $0 per day, days 6-90 in-network / 50% per stay out-of-network. Urgent care. Plan Name Effective Year Benefit Package Summary; H5322-031 - UnitedHealthcare Dual Complete LP (HMO D-SNP) 2023: H5322-031: Download: AARP Medicare Advantage Plan 1 (HMO-POS)Y0066_ANOC_H5322_031_000_2023_M. Y0066_210610_INDOI_C Find updates to your plan for next year This notice provides information about updates to your plan, but it ...2022 Summary of Benefits GNHH4HIEN_22_C H5216228000SB22 SBOSB035 HumanaChoice SNP-DE H5216-228 (PPO D-SNP) Oklahoma Select Counties in Oklahoma Introduction If you have a medical emergency, get help as quickly as possible. Call 911 or go to the nearest emergency room or hospital. Emergency care can always be obtained in or out of the service areaResources and tools for providers and health care ...2019 Medicare Advantage Plan Benefit Details for the UnitedHealthcare Dual Complete (HMO SNP) - H5322-031-0 This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans. Provider Directory 2023 UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) Oklahoma Alfalfa, Atoka, Beaver, Beckham, Blaine, Caddo, Choctaw, Cimarron, Coal, Comanche ... Jan 1, 2023 · H5322-033-000 Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan. Toll-free 1-844-560-4944, TTY 711 8 a.m.-8 p.m. local time, 7 days a week UHCCommunityPlan.com Y0066_SB_H5322_033_000_2023_M o UnitedHealthcare Dual Complete® LP (HMO-POS D-SNP) H5322-031-000 - UL4 Information about you (Please type or print in black or blue ink) Last Name First Name Middle Initial Birth Date Sex ¨ Male ¨ Female Home Phone Number ( ) - Mobile Phone Number ( ) - Social Security Number Y0066_EOC_H5322_031_000_2023_C. OMB Approval 0938-1051 (Expires: February 29, 2024) January 1 – December 31, 2023 Evidence of Coverage .