Get 2016 Advantage Plus Enrollment Form Ca - Kaiser Medicare

Filling out the 2016 Advantage Plus Enrollment Form CA - Kaiser Medicare online is a straightforward process that enables you to take advantage of enhanced healthcare benefits. This guide provides you with clear, step-by-step instructions to ensure a smooth and efficient enrollment experience.

Follow the steps to complete your enrollment form online.

1. Click the ‘Get Form’ button to obtain the enrollment form and open it in your browser.
2. Begin by entering your last name and first name in the designated fields. Ensure that your spelling is accurate.
3. Provide your date of birth in the format mm/dd/yyyy. This is important for verifying your eligibility.
4. Select your gender by ticking the appropriate box.
5. Fill in your email address (optional) to receive updates regarding your application.
6. Enter your middle initial, if applicable.
7. Input your home phone number, including the area code, in the provided space.
8. Locate your Medicare Claim number on your Medicare card and enter it in the specified field.
9. Provide your permanent residence address, including street, city, state, and ZIP code. Do not use a P.O. box.
10. If your mailing address differs from your permanent address, fill in the mailing address fields, including street, city, state, and ZIP code. P.O. boxes are acceptable here.
11. Indicate whether you are currently enrolled in or have recently applied for a Kaiser Permanente Senior Advantage plan by selecting ‘Yes’ or ‘No.’
12. If you answered ‘Yes’ to the previous question, enter your Kaiser Permanente Medical Record Number (MRN) in the designated field.
13. Review the conditions of enrollment section and acknowledge your understanding by signing the application. If someone is signing on your behalf, they must provide their information in the authorized representative section.
14. Enter the date you signed the form.
15. If applicable, provide the name, relationship to you, address, and phone number of your authorized representative.
16. Once all fields are completed accurately, save any changes, and download or print the completed form.

Take the next step in managing your healthcare by completing the Advantage Plus Enrollment Form online.