Enrollment in Fox Rx Care is easy..
There are three different ways that you can complete the form to enroll with us:
- Easiest: Call us toll free at 1-888-FOX-RxRx(1-888-369-7979)/ (1-888-369-7373) 8 am to 8 pm, 7 days a week, TTY/TDD users should call 1-866-369-7373 , and we will fill out the form with you over the telephone.
- Simplest: We would send you an enrollment information kit or you can download it here. Complete the enrollment form that is in this packet. The Enrollment form is self explanatory. The instruction for completion of each item on the form is in the following table for your reference if you need it, or if you get stuck you can call us to help you to complete the paper form. if you have questions you can call us to help you to complete the paper form. After it is completed, you simply stick it in the pre-addressed envelope that is included and mail it to us. If you have a fax machine, you can use the toll free fax number below for even first processing.
- Fastest: For those who are computer savvy, or have help in enrollment you may use our Online Web Enrollment Form.
We are here to help you regardless of how you choose to enroll. We know that some of you will have help in the enrollment process and we provide as many options as possible to get your enrollment completed and finalized as painlessly as possible.
We will keep you informed.
After we receive your enrollment request, we will process it into our automated system. If we find that we have a problem or need some additional information we will call or contact you by mail to obtain the additional information.
When we have all the information that is needed, we will submit your enrollment to CMS. Shortly after, you will receive a letter from Fox Rx Care indicating that your enrollment has been submitted to CMS.
After CMS responds we will notify you of the accepted enrollment. You will receive an Enrollment Package, and your Identification Card will be sent to you before your eligibility begins.
If you have any questions or need any clarification, please call us at toll free:
1-888-FOX-RxRx (1-888-369-7979)
TTY /TDD users should call 1-866-369-7373.
Please mail the completed form to:
Fox Insurance Company
40 West 25th Street, 6th Floor
New York, New York 10010
You can also fax the form toll free to 1-866-369-7978
Email it to enrollment@foxrxcare.com
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INSTRUCTION FOR COMPLETING THE ENROLLMENT FORM
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ITEM
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HOW TO COMPLETE
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Plan to Enroll In
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Please check the box of which plan you would like to enroll in.
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Last Name
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Please enter your last name
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First Name
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Please enter your first name
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Middle Initial
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Please enter your middle initial, if applicable.
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Salutation
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Please check one box.
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Birth Date
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Please enter your birth date.
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Sex
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Please check one box.
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Social Security
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Please enter your SSN.
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Home Phone Number
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Please enter your home phone number. You can enter more than one number, e.g. land-line and cell phone number.
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Permanent Residence Address
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Please enter your permanent residence address (where you live for last six months of the year).
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Mailing Address
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Please provide your mailing address only if it is different from your permanent residence address.
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Emergency Contact
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Please provide the details for a person we may contact in case of an emergency.
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Email Address
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Please provide your email address if you have one.
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Medicare Insurance Information
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Please enter your information as it appears on your Medicare card or attach a copy of your Medicare card or your letter from Social Security Administration or Railroad Retirement Board.
Please provide your Medicare Claim Number (HIC Number) and your Medicare Part A & Part B Entitlement Effective dates exactly as they appear on the card.
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Plan Premium Payment Option
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Please check the appropriate box to indicate whether you want your monthly premium automatically deducted from your Social Security check or whether you would prefer to pay it yourself via a check, credit card or other electronic funds transfer
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Medicare Coordination of Benefits
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Please list all other drug coverage that you may have including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits or State pharmaceutical assistance programs.
You can find the ID number and group number for your other coverage on the ID card that you have.
If you need additional spaces, please use a separate sheet.
Please also check the appropriate box if you are a resident in long term care facility, such as nursing home.
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Signing the form
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Please don’t forget to sign and date the form before sending it to us to avoid any delay in processing. If somebody helps you in completing the form please have the authorized representative sign and date the form.
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Send it to us
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Please send it to us using the envelope provided or other methods.
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If you need additional copies of the enrollment form, you can download the form from our website at:
www.foxrxcare.com
or call us at toll free:
1-888-FOX-RxRx (1-888-369-7979)
TTY/TTD Users should call: 1-866-369-7373