Get 903207 Moda Health Ppo And Pporx 2014 Combined Enrollment Form.indd

Filling out the 903207 Moda Health PPO And PPORX 2014 Combined Enrollment Form online is a straightforward process that can help you complete your enrollment in a Moda Health plan efficiently. This guide will provide you with step-by-step instructions to ensure that you fill out the form accurately and understand each section's requirements.

Follow the steps to complete the enrollment form online.

1. Click the ‘Get Form’ button to obtain the form and open it for editing in your online tool.
2. Select the plan you wish to enroll in by checking the appropriate box and noting any optional supplemental benefits.
3. Fill in your personal information including last name, first name, middle initial, birth date, and sex. Make sure the details are accurate and match your identification.
4. Provide your home phone number and an alternate telephone number where you can be reached.
5. Enter your permanent residence street address. Note that a P.O. Box is not acceptable.
6. If your mailing address is different from your permanent address, provide that information as well.
7. Input your email address for communication purposes.
8. Complete the Medicare insurance information section by matching the details to your Medicare card. Ensure that the Medicare claim number, effective dates for Parts A and B, and personal information are correctly entered.
9. Select your monthly premium payment option. You can choose to pay via a bill, electronic funds transfer, eBill, or automatic deduction from Social Security benefits. Provide the necessary details for your selected payment method.
10. Answer the eligibility questions regarding your health coverage and status accurately, including any other prescription drug coverage and additional relevant information.
11. Read and acknowledge the important information regarding your enrollment. Then, provide your signature and today’s date to finalize your application.
12. If required, include any additional information or signatures if you are an authorized representative.
13. Finally, save the completed form, then download, print, or share it as needed for submission.

Complete your enrollment form online today to secure your Moda Health coverage.