Health First Health Plans

Broker Referral Form
for referring prospective Medicare Advantage members

Please complete all required fields below and click submit. Commissions will pay after the member is sold and has been enrolled 90 days.

Important Reminder:

The prospective member must contact our Customer Service Department with any questions or to request an enrollment form or in-home appointment. The prospective member may call the agent or agency they wish to represent them, or they can always contact Health First Health Plans directly at 1.800.716.7377 weekdays from 8 a.m. to 8 p.m. and Saturdays from 8 a.m. to noon. From October 1 to March 31, Health First Health Plans is available seven days a week from 8 a.m. to 8 p.m.
Per the Center for Medicare & Medicaid Services (CMS) Health First Health Plans cannot reach out to the prospective member.

Prospective Member

First and Last Name*

Address*

City*

State*

ZIP Code*

Phone

Date of Birth

Referring Broker

First and Last Name*:

National Producer Number (NPN)*:

Agency Affiliation:

Phone:

Email:

Referral Details

This prospective member was developed during the normal course of business by the broker?*

This prospective member is a current client of the broker?*

This prospective Member initiated contact with the broker?*

This prospective member was recently retired from a group plan represented by the broker?*

Proposed effective date for prospective member?*

Referring broker will refer this prospective member to*:

If Other Medicare Sales Agent/Agency was elected, enter the name of that Agent/Agency here:

Note: Referral must be submitted before the effective date of the member enrolling with Health First Health Plans, and member must enroll within three months of submitted referral and must be enrolled for at least 90 days.

Disclaimer: Health First Physicians and Health First licensed sales associates are excluded from participating in the program. Health First Health Plans (Health First Health Plans) does not allow the sale of a Medicare Advantage product to a Medicare eligible by anyone other than an employed associate with an active Florida Health Insurance license, appointed with Health First Health Plans and who has successfully completed their AHIP certification.

Health First Health Plans Medicare Sales Representatives are responsible for presenting the sale and assisting in the completion of the prospect's application for enrollment. The prospective member must be directed to contact the agent or agency they wish to represent them. Or prospective members can always contact Health First Health Plans directly at 1.800.716.7377 to complete enrollment.

Per the Centers for Medicare & Medicaid Services (CMS) Health First Health Plans cannot outreach to the prospective member.

In accordance with our contract with CMS, Health First Health Plans has the right to monitor compliance through analysis of complains or enrollee satisfaction surveys, rapid disenrollment surveys and other sources of enrollee input. Health First has the right to exclude an associate from participation if results indicate Health First Health Plans is not appropriately represented. HF Associates who are also Health First Health Plans MA members cannot participate and must be excluded per CMS Section 30.16 of Chapter 3.

It is non permissible, per CMS, to pay both a referring commission and a sales commission to the same broker

AdventHealth Advantage Plans is administered by Health First Health Plans. Health First Health Plans is an HMO plan with a Medicare Contract. Enrollment in Health First Health Plans depends on contract renewal.

Y0089_EL8540AH_M | Accepted date: 10/01/2020
Last updated: 08/13/2021

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