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Follow these guidelines and be sure to complete all required fields:
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Select the plan you wish to enroll in.
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Enter your name as it appears on your Medicare Card.
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If your mailing address is different from your home address, please include under "Mailing Address".
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Include your full date of birth, including 4-digit year of birth. For example: 05/21/1930
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If a Power of Attorney or Guardian is completing this application, please complete Section 5, including your address,
phone number, and relationship to enrollee. If a legal representative signs the form for the applicant, then a copy
of the court order appointing the representative as legal guardian, durable power of attorney for health care decisions,
or proof of other authorization required by State law that empowers the individual to effect an election on behalf of the
applicant must be available upon request by the Plan or by the Centers for Medicare and Medicaid Services, the Federal
Agency that runs Medicare.
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