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Champion Questionnaire
Have you ever been diagnosed with End Stage Renal Disease or currently receiving dialysis treatment?
Yes
No
Champion Health Plan is a Medicare Advantage Prescription Drug HMO Chronic Condition Special Needs Plans for Medicare beneficiaries with End Stage Renal Disease. If you believe you qualify to enroll with Champion Health Plan, please call us at 1-800-885-8000. Thank you for your interest in Champion Health Plan.
Which state do you live in?
CA
NV
Other
Thank you for your interest in Champion Health Plan. You may not live in our service area. Please call 1-800-885-8000 to speak with a Champion Health Plan representative if you have questions.
Which CA county do you live in?
Fresno
Los Angeles
Madera
Orange
Riverside
San Bernardino
San Diego
Other
Thank you for your interest in Champion Health Plan. You may not live in our service area. Please call 1-800-885-8000 to speak with a Champion Health Plan representative if you have questions.
Which NV county do you live in?
Carson City
Churchill
Clark
Washoe
Other
Thank you for your interest in Champion Health Plan. You may not live in our service area. Please call 1-800-885-8000 to speak with a Champion Health Plan representative if you have questions.
Do you have Part A & Part B of Medicare?
Yes
No
Champion Health Plan is a Medicare Advantage Prescription Drug HMO Chronic Condition Special Needs Plans for Medicare beneficiaries with End Stage Renal Disease. If you believe you qualify to enroll with Champion Health Plan, please call us at 1-800-885-8000. Thank you for your interest in Champion Health Plan.
Do you get help with your costs from one of these programs?
Medicaid / Medi-Cal
Extra Help for Rx
No
I'm not sure
Which plan year are you interested in?
2024
2025
Have you ever been diagnosed with End Stage Renal Disease or currently receiving dialysis treatment?
Yes
No
Champion Health Plan is a Medicare Advantage Prescription Drug HMO Chronic Condition Special Needs Plans for Medicare beneficiaries with End Stage Renal Disease. If you believe you qualify to enroll with Champion Health Plan, please call us at 1-800-885-8000. Thank you for your interest in Champion Health Plan.
Which state do you live in?
CA
NV
Other
Thank you for your interest in Champion Health Plan. You may not live in our service area. Please call 1-800-885-8000 to speak with a Champion Health Plan representative if you have questions.
Which CA county do you live in?
Fresno, Los Angeles, Madera, Orange, Riverside, San Bernardino, San Diego
Other
Which CA county do you live in?
Imperial, Fresno, Kern, Los Angeles, Madera, Orange, Riverside, San Bernardino, San Diego
Other
Thank you for your interest in Champion Health Plan. You may not live in our service area. Please call 1-800-885-8000 to speak with a Champion Health Plan representative if you have questions.
Which NV county do you live in?
Carson City, Churchill, Clark, Washoe
Other
Thank you for your interest in Champion Health Plan. You may not live in our service area. Please call 1-800-885-8000 to speak with a Champion Health Plan representative if you have questions.
Do you have Part A & Part B of Medicare?
Yes
No
Champion Health Plan is a Medicare Advantage Prescription Drug HMO Chronic Condition Special Needs Plans for Medicare beneficiaries with End Stage Renal Disease. If you believe you qualify to enroll with Champion Health Plan, please call us at 1-800-885-8000. Thank you for your interest in Champion Health Plan.
Do you get help with your costs from one of these programs?
Medicaid / Medi-Cal
Extra Help for Rx
No
I'm not sure
