Get Enrollment Request Form - Cusd Claremont

Completing the Enrollment Request Form for UnitedHealthcare Group Medicare Advantage plans can seem daunting, but this guide simplifies the process. Follow these steps to ensure a smooth completion of the form online.

Follow the steps to successfully fill out your Enrollment Request Form.

1. Press the ‘Get Form’ button to obtain the Enrollment Request Form and open it in your preferable online editor.
2. In the Plan Information section, verify that your Plan Sponsor, Group Number, and GPS # are correctly stated. If any information is incorrect or missing, provide the correct details. Indicate the date when you expect your coverage to begin and write the name of your selected Primary Care Physician (PCP) along with their Provider number.
3. In the Applicant Information section, fill in your name exactly as it appears on your Medicare card. Ensure you complete a separate form for any eligible spouse and/or dependents. Attach a copy of your Medicare card or your Letter of Verification from the Social Security Administration if available.
4. Move to the Medical Information section and answer questions regarding End-Stage Renal Disease (ESRD). If applicable, provide the duration of your Medicare coverage for ESRD.
5. Sign and date the Enrollment Request Form using a ballpoint pen. If someone assisted you in filling out this form, they must also sign and indicate their relationship to you. Include documentation if applicable.
6. Complete the return section by sending the finished Enrollment Request Form in the provided self-addressed, postage-paid envelope or to the specified address for UnitedHealthcare.
7. After submission, remember that you will receive an Acknowledgement Notice which will serve as your temporary Plan member ID card. This notice will confirm that your enrollment request has been received.
8. Double-check all completed information for accuracy before finalizing. Once satisfied, save your changes if using an online format, or download, print, or share the form as per your needs.

Complete your Enrollment Request Form online today for a smoother enrollment experience.