Get Priority Health Medicare Enrollment Request Form

The Priority Health Medicare Enrollment Request Form allows users to enroll in Medicare Advantage plans efficiently online. This guide provides a comprehensive overview of the form, helping you understand each section and complete it accurately.

Follow the steps to successfully complete your enrollment form

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Read the attestation of eligibility carefully. You must check the box corresponding to the statement that applies to your situation, certifying your eligibility for enrollment.
3. Provide your personal information, including your name, date of birth, and contact details. Ensure that your permanent residence address is accurate, as P.O. Boxes are not permitted.
4. Select your desired Medicare plan by checking the appropriate box for either PriorityMedicare Value, PriorityMedicare, or PriorityMedicare Select.
5. If applicable, choose a primary care provider (PCP) by entering their name. This is optional for the PPO plan.
6. Indicate whether you wish to enroll in the enhanced dental plan. If you opt for it, note the effective date and understand the additional premium involved.
7. Complete the Medicare insurance information section, referring to your Medicare card to ensure accuracy or attach a photocopy for verification.
8. Select a payment option for your plan premium. You can choose to receive a bill by mail, use electronic funds transfer (EFT), or have payments deducted from your Social Security benefit.
9. Answer all five important questions on the form honestly, as they relate to your health coverage and eligibility.
10. Sign and date the form at the bottom to confirm that you agree with the terms and conditions stated.
11. Mail your completed enrollment form using the enclosed postage-paid reply envelope or send it to the provided address if you lack one.
12. After submission, stay alert for a confirmation call from Priority Health to verify your understanding of your chosen plan's rules and benefits.

Complete your Priority Health Medicare Enrollment Request Form online today to secure your Medicare Advantage plan.