Get 866 802 6062

Filling out the 866 802 6062 form online is a straightforward process that ensures your information is accurately submitted. This guide provides step-by-step instructions to help you navigate each section with ease.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to obtain the necessary form and open it for editing.
2. In the ‘Enrollee Name’ section, fill in the required fields: First name, Middle Initial, and Last name. Ensure that each part is complete, as these are mandatory fields.
3. Enter your date of birth in the specified format. This information is crucial for identification purposes.
4. Provide your Member ID and Medicare Claim Number accurately to avoid any discrepancies.
5. Indicate the effective dates for Medicare Part A and Part B as required.
6. Attach proof of Medicare A and B by providing copies of the respective Award Letters or Medicare Cards, if applicable.
7. Complete the 'Agent Name' and 'Agent ID' sections, which are necessary for the application process.
8. If you are not the Agent of Record, fill in the required 'Contact Name' field along with an email address where responses can be sent.
9. Input your effective date, election period, and plan selection information accurately.
10. If applicable, provide the reason for using a Special Election Period (SEP).
11. Fill out your permanent address details, including city, state, and ZIP code, and provide a phone number.
12. If your mailing address is different, fill that in as well with the necessary information.
13. Check the appropriate box related to your application status and specify any actions needed or updates requested in the provided space.
14. Attach any supporting documents as necessary.
15. Ensure that all emails containing Personal Health Information (PHI) or Personally Identifiable Information (PII) are encrypted before submission.
16. Once you have completed the form, review your entries, save your changes, and opt to download, print, or share the form as needed.

Begin your application process by completing the 866 802 6062 form online today.