Get Regence Medadvantage Ppo Enrollment Request Form On Line

Filling out the Regence Medadvantage PPO Enrollment Request Form online can streamline your enrollment process and help you secure your healthcare coverage. This guide provides clear, step-by-step instructions to assist users in completing the form correctly and efficiently.

Follow the steps to complete your enrollment request form.

1. Click the ‘Get Form’ button to obtain the enrollment request form and open it in your editor.
2. Select the plan you wish to enroll in. Options include Regence Medadvantage + Rx Enhanced, Regence Medadvantage + Rx Classic, and Regence Medadvantage Basic. Check the appropriate box next to your selected plan.
3. Enter your personal information including last name, first name, middle initial, birthdate, sex, home phone number, and alternate phone number in the provided fields.
4. Provide your permanent residence address, ensuring that a P.O. box is not included. Fill in the city, state, and ZIP code.
5. If your mailing address is different from your permanent residence address, include that information here along with the appropriate phone number.
6. Fill in your emergency contact's name, phone number, and relationship to you.
7. Enter your email address for any communication regarding your enrollment.
8. Provide your Medicare insurance information by entering details exactly as they appear on your Medicare card. Alternatively, you may attach a copy of your Medicare card.
9. Select your preferred method of paying your plan premium from options such as getting a bill, electronic funds transfer, or automatic deduction from Social Security or Railroad Retirement Board benefits.
10. Answer important questions regarding your health status and any additional drug coverage you may have. Ensure you provide accurate information to avoid enrollment issues.
11. Check the boxes that apply to your enrollment eligibility and provide any necessary dates.
12. Read and acknowledge the important information provided regarding your eligibility, and conditions of plan enrollment.
13. Sign the application, and provide the date and information if you are signing on behalf of another person.
14. Once you have filled out the form completely, you can save changes, download a copy, or print the document for your records.

Complete your enrollment request form online today to ensure your healthcare coverage is secured!