Medicare Insurance Plan ENROLLMENT QUESTIONS - leave fields blank that are not applicable or put NA

Medicare Insurance Plan ENROLLMENT QUESTIONS - leave fields blank that are not applicable or put NA

This form is Needed to submit an enrollment application for Medicare Supplement, Medicare Advantage and/or Prescription Drug Coverage (enrollment will not be transmitted for either without your final verbal consent, this makes the enrollment process much quicker).
Name as it appears on Medicare Card
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
County of Residence
Mailing address if different from above

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Best phone number

Area Code Phone Number
Email
example@example.com
Social Security Number (for Medicare Supplement or Special Needs Plan only)
DOB

Month Day Year
Date
MEDICARE #
PART A EFFECTIVE DATE

Month Day Year
Date
PART B EFFECTIVE DATE

Month Day Year
Date
Effective Date of policy Requested

Month Day Year
Date
Information on all Physician & Specialists, address where seen, phone number with area code
Conditions you are being treated for and how often?
Insurance Company Requested
Prescription Drugs taking optional but helps you price compare and choose the right Prescription plan* (include name and dosage)
Plan Name
Anticipated Monthly Premium
Name of the Pharmacy you like to use
How would you like to pay your Part D premium?

EFT/Bank Draft (preferred) Monthly invoice & check SSA deduction (not recommended)
Name of Bank: For monthly premium draft (MED SUPP and/or Part D)
Routing Number
Account Number
Date of the month for reoccurring draft (first month’s premium is drafted immediately)
Would you like to keep files organized and GO GREEN by getting plan mail electronically?

YES NO, postal mail please
Current Insurance
Approximately when did your current insurance start?

Month Day Year
Date
DO NOT CANCEL ANY COVERAGE UNTIL NEW COVERAGE IS IN PLACE. I will send you guidance when the time comes. Click to edit this text.

Part D or Medicare Advantage plans do not need to be canceled because Medicare will do it automatically upon approval of the new plan.
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