Get Form 6200 Py2020 - Medicare Eligible Insurance Application

This guide provides comprehensive instructions for filling out the Form 6200 PY2020 - Medicare Eligible Insurance Application online. Follow the steps carefully to ensure your application is completed accurately and successfully.

Follow the steps to complete the form online.

1. Press the ‘Get Form’ button to obtain the form and open it in your document editor.
2. Fill in the Enrollee Information section. This includes the enrollee's name, social security number, retiree name, member ID, date of birth, email, and phone number.
3. Complete the Permanent Residence Street Address field with the actual street address. Note that a P.O. Box is not acceptable. Also, provide the state, city, and zip code.
4. If your mailing address differs from your permanent residence, fill in the Mailing Address section, including the state, city, and zip code.
5. Indicate your relationship to the retiree, choosing from the options: spouse, dependent child, or other (explain).
6. Attach a copy of your Medicare Card or Social Security Awards Letter if it is not already on file.
7. Respond to the question regarding End-Stage Renal Disease (ESRD). If applicable, attach a note or records from your doctor.
8. Provide details on Employment After Retirement, indicating if the enrollee is employed, self-employed, eligible, and enrolled in an Employer's Group Health Plan.
9. If applicable, fill in your retirement date.
10. Review the Paying Your Plan Premium section, ensuring you do not submit any payments for Part D-IRMAA fees to the Kentucky Retirement Systems.
11. If you are an authorized representative, include necessary documentation of your legal authority to complete the form.
12. Read the release of information clause carefully and check for accuracy.
13. Sign and date the application, including the retiree’s signature if different from the applicant.
14. Return your completed Enrollment Form to the Kentucky Retirement Systems at 1260 Louisville Road, Frankfort, KY 40601-6124.

Complete your Form 6200 PY2020 online today to ensure your Medicare coverage.