Attachment 6H - Service Package Brochure.pdf

4. Terms of Use -- Please Read The Following Terms And Conditions Carefully and Sign Below:

TERMS AND CONDITIONS OF USING THE FEDERAL LONG TERM CARE SERVICE PACKAGE

a. LifePlans, Inc. and its employees (collectively referred to as "We" or “Our”) are the authorized provider and administrator of the Federal Long Term Care Service Package (the Service Package). We are a subcontractor of Long Term Care Partners, LLC, the administrator of the Federal Long Term Care Insurance Program.

b. We do not sell, rent, give away or loan any identifiable information regarding Our customers to any third party. We will not disclose any of your personal information, except to Long Term Care Partners, LLC. If We are required by law to dis-close any information, including registration data, We will let you know.

c. The information We provide to you is intended solely as a general educational aid and is neither medical nor health care advice for any individual problem. The information is also not meant as a substitute for medical or other professional advice and services from a qualified health care provider familiar with your unique health history and facts.

d. We will take all reasonable steps to assure the accuracy and completeness of all information We provide as part of the Service Package. However, We are not able to guarantee it, since it may have changed since We provided it to you.

It is your ultimate decision as to whether to use or not use information. As such, We are not liable for the consequences resulting from those decisions.

e. If at the time you renew your enrollment, the Service Package and/or its fee has changed since you last enrolled, We will let you know.

f. If you are not satisfied with the Service Package, please notify us in writing at the address on the front of this form within 30 days of enrollment, and We will refund your money.

g. The Terms and Conditions of this agreement apply to the enrollees whose names and other identifying information appear on the reverse side of this Enrollment Form.

By signing below, I agree to the terms and conditions specified above.

Primary Enrollee’s Signature:_______________________________________________________Date________/_______/_______ Month Day Year

Spouse’s Signature (if requesting enrollment):________________________________________Date_______/_______/_______ Month Day Year

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ENROLLMENT FORM

FOR THE FEDERAL LONG TERM CARE SERVICE PACKAGE

Choose One: New Renewal

The Service Package is only available to the groups shown.

Tell us which of these describes the PRIMARY ENROLLEE. Please check one.

Federal/Postal employee Current spouse of a Federal/Postal employee or Member of the uniformed services member of the uniformed services Federal/Postal annuitant Current spouse of a Federal/Postal annuitant Retired member of the uniformed services or retired member of the uniformed services Parent, parent-in-law, or stepparent of Surviving spouse receiving a survivor annuity living Federal/Postal employee or living Adult child (at least 18 years old, including adopted member of the uniformed services children or stepchildren) of a living Federal/Postal employee or living member of the uniformed services

1. Personal Information for PRIMARY ENROLLEE Name ________________________________________________________________________________________________

FIRST MIDDLE LAST

Street Address ________________________________________________________________________________________

City _________________________________State__________________________Zip_______________________________

Social Security Number __________-___________-__________ Date of Birth ____________/____________/ ________ Month Day Year

Home Phone _____________________Work Phone _____________________ Email ____________________________

2. Spouse Enrollment

Would you like to enroll your spouse in the Service Package? There is no additional charge.

No Yes If "Yes" please complete the information below:

Spouse’s Name _______________________________________________________________________________________

FIRST MIDDLE LAST

Social Security Number __________-___________-___________ Date of Birth___________/_________/____________ Month Day Year

3. Method of Payment -- Payment is required before using the Service Package. THE ANNUAL FEE IS $59.00 Check enclosed payable to: LifePlans, Inc. Service Package Check # _________________________________

Charge to: MasterCard Visa Discover Expiration Date:__________________________

Card Number:__________________________________Card Holder Name:_____________________________________

Billing Address: _______________________________________________________________________________________ Street City State Zip Code

Signature: ____________________________________________________________________________________________

--TURN OVER AND COMPLETE OTHER SIDE OF FORM--

Mail completed form with check or credit card information in the enclosed postage-paid reply envelope. If you don’t have the envelope return to:

LifePlans, Inc.

Attn: Federal Long Term Care Service Package 51 Sawyer Road, Suite 340 Waltham, MA 02453 Phone: 1-800-886-7554 (TDD: 1-800-886-7598)

Clip and Mail

T h e F ed eral L o n g Term

C are S ervice P ack age (th e S ervice P ack age) h elp s to gu id e yo u th ro u gh th e co m p lex m aze o f lo n g term care services, fin d so lu tio n s to yo u r care n eed s, m ain tain yo u r q u ality o f life, an d p ro vid e p eace o f m in d

W h at is th e S ervice P ack age?

T h e S ervice P ackage is a n on

-in su ran ce op tion u n d er th e F ed eral L on g Term C are In su ran ce P rogram p rovid ed th rou gh

L ifeP lan s, In

c. A p rem ier p rovid er of lon g term care m an agem en t p rod u cts an d services, L ifeP lan s, In c., is th e exclu sive p rovid er of th e F ed eral

L on g Term C are S ervice P ackage. T h e S ervice P ackage p rovid es you w ith access to a care coord in ator, gen eral in form ation an d referral services an d access to a d iscou n ted n etw ork of lon g term care p rovid ers an d services.

M ore sp ecifically, b y en rollin g in th e S ervice P ackage, you w ill h ave access to th e follow in g:

• C are coord in ators -- n u rses w h o are sp ecialists in lon g term care an d lon g term care services an d p rovid ers. O u r care coord in ators listen to you r con cern s an d assist you w ith solu tion s to m eet you r in d ivid u al n eed s;

• In form ation al m aterial on lon g term care issu es;

• R eferrals to lon g term care p rovid ers, services an d oth er resou rces;

• D iscou n ts of b etw een

5% -15% on a variety of lon g term care service p rovid ers in clu d in g n u rsin g facili-ties, assisted livin g facilities, h om e care services, as w ell as p rovid ers of m ed ical equ ip m en t an d oth er related p rod u cts.

W h o S h o u ld

C o n sid er E n ro llin g in th e S ervice P ack age?

T h e S ervice P ackage is availab le to all m em b ers of th e

F ed eral F am ily w h o ap p lied for in su ran ce coverage u n d er th e F ed eral L on g Term

C are In su ran ce P rogram an d w ere d eclin ed

If you are a qu alified relative of som eon e w h o is in su red u n d er th e F ed eral L on g Term

C are In su ran ce

P rogram

, you m ay n ot n eed to en roll in th e S ervice

P ackage. Y ou alread y h ave access to care coord in ation services an d d iscou n ts th rou gh th at p erson

T h e S ervice P ackage p rovid es access to services an d d iscou n ts on ly w ith in th e U n ited S tates an d its territo-ries an d p ossession s (“U n ited

S tates”). T h e S ervice P ackage is n ot availab le ou tsid e th e U n ited

S tates. If an d w h en you retu rn to th e U n ited

S tates you m ay en roll in th e S ervice P ackage.

A n n u al C o st T h e an n u al fee is $59.00; th at’s less th an $5.00 p er m on th

! T h e fee covers th e tw elve-m on th p eriod b egin n in g on th e d ate w e receive all en rollm en t in form ation

Y ou an d you r sp ou se are covered b y on e an n u al fee.

T h e an n u al fee covers gen eral in form ation

, con su lta-tion

, an d referral to services an d p rovid ers.

T h ere is an ad d ition al fee for telep h on ic or on

-site assessm en t of you r lon g term care n eed s an d d evelop m en t of a P lan of C are (a P lan of C are is a cu stom ized an d d etailed service p lan th at in clu d es locatin g care-givers an d services you n eed to care for you

B ecau se th is is N

O T an in su ran ce p rogram

, you are resp on sib le for th e p aym en t of an y fees to th e p rovid ers th at you ch oose. W e w ill alw ays tell you in ad van ce if th ere is a cost for services.

H o w to

E n ro ll

Y ou can en roll in th e S ervice P ackage at an y tim e.

C om p lete th e en closed en rollm en t form an d retu rn it in th e p ostage-p aid en velop

e. B e su re to in clu d e you r an n u al fee, p ayab le b y cred it card or p erson al ch eck.

Y ou can also en roll over th e p h on e M on d ay th rou gh

F rid ay 8:00 a.m . to 8:00 p

.m . E astern Tim e u sin g a cred it card p aym en

t. T h e telep h on e n u m b er is

1-800-886-7554 (T D

D : 1-800-886-7598).

H ere’s H o w th e S ervice P ack age W o rk s

Y ou w ill receive a W elcom e K it w ith ou r toll-free tele-p h on e n u m b

er. Y ou can ren ew you r S ervice P ackage en rollm en t on an an n u al basis. If, at th e tim e you ren ew you r en rollm en t, th e S ervice P ackage an d

/or its fee h as ch an ged sin ce you last en rolled , w e’ll let you kn ow