Medicare Group Enrollment Form

A: To enroll in Medicare Group, please provide the following information

For new member enrollments or administrative changes to existing subscribers

For administrative changes to existing subscriber information only

New Subscriber

NoYes

Desired Effective Date of Coverage

SSN

Group #

Group Product

Group Name

Last Name

First Name

Middle Initial

Birth Date

Sex

Salutation

Contact Phone Number (optional)

Email Address (optional)

Permanent Residence Street Address (P.O. Box is not allowed)

Address 1

Address 2

City

State

Zip Code

Mailing Address (only if different from your Permanent Residence Address):

Address 1

Address 2

City

State

Zip Code

Emergency Contact

Emergency Contact Phone Number

Relationship to You

Employer/Union:

Name of Employer/Union (Past or Present)

Group #

Desired Effective Date

B: Please provide your Medicare insurance information

Name (as it appears on your Medicare card)

Medicare Number

Hospital (Part A) Eff. Date

Medical (Part B) Eff. Date

Primary Care Physician

Election Period

Payment Type

Physician Code Number

C: Please answer the following questions

Will you have other prescription drug coverage (like VA, TRICARE) in addition to Select Option PDP?

No
Yes

Name of other coverage

ID# for this coverage

Group# for this coverage

Are you a resident in a long-term care facility, such as a nursing home?

No
Yes

Name of Institution

Phone Number of Institution

Address of Institution

Please check one of the boxes below if you would prefer us to send you information in a language other than English or in an accessible format:

Braille

Audio Tape

Large Print

Other language (please specify)

Please check this box to confirm that you are enrolling this retiree into this Medicare Group plan.

NoYes

Today’s Date

If you are the authorized representative, you must provide the following information:

Name

Phone Number

Relationship to Enrollee

Address 1

Address 2

City

State

Zip Code

Group Benefit Administrator submitting this form (required)

Last Name

First Name

Middle Initial

Phone Number

Address 1

Address 2

City

State

Zip Code