Get Co 2/213-pcretpm (formerly 2/74-pcretm) 2019

Filling out the CO 2/213-pcretpm (Formerly 2/74-pcretm) online can streamline your enrollment or changes to your Medicare coverage. This guide provides step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Provide your personal information in the designated fields. Enter your full name, permanent residence address (no P.O. Box), daytime phone number, and email address. Indicate whether you would like to sign up for electronic delivery of PERA information by checking 'Yes' or 'No'.
3. Sign the certification section to confirm your eligibility and authorize the necessary deductions for your coverage. If applicable, have your spouse sign the form as well.
4. Request your effective date for enrollment, change, or cancellation. Ensure to enter a valid date if not coinciding with your retirement effective date.
5. If enrolling dependents, fill out the dependent enrollment information, including names, birthdates, and social security numbers. Make sure your spouse's signature appears if you are adding their coverage.
6. For the Medicare information section, indicate if you are enrolling in a health plan by checking the appropriate options for yourself, your spouse, and your child. Send a photocopy of your Medicare card(s) as soon as you receive them.
7. Select your desired health plan and level of coverage, whether to enroll in or change your dental and vision plans as needed. Each selection should be carefully checked and confirmed.
8. Review all entries for accuracy before saving your changes. You can then download, print, or share the completed form.

Complete your CO 2/213-pcretpm (Formerly 2/74-pcretm) form online to manage your Medicare coverage effectively.