Get Enrollment Request Form - Providence Health Plans - Healthplans Providence

Filling out the Enrollment Request Form for Providence Health Plans is a straightforward process designed to help you enroll in the Medicare Advantage plans offered. This guide will walk you through each step to ensure you accurately complete the form and provide all necessary information.

Follow the steps to successfully complete the enrollment request form.

1. Click ‘Get Form’ button to obtain the Enrollment Request Form and open it in the document editor.
2. Begin by entering your name as it appears on official documents. Include your last name, first name, and middle initial if applicable.
3. Provide your birth date and sex. Be sure to format the date correctly as MM/DD/YYYY.
4. Enter your home phone number in the specified format, ensuring accuracy for contact purposes.
5. Fill out your permanent residence street address. Note that P.O. Box addresses are not accepted. Include your city, county, state, and ZIP code.
6. If you have a different mailing address, complete the additional section with the same details including street address, city, state, and ZIP code.
7. Indicate if you need help by providing an emergency contact's details, including their name, phone number, and your relationship to them.
8. In the Medicare insurance section, match the details with your Medicare card. This includes your name, Medicare claim number, and effective dates for Part A and Part B.
9. Select your Medicare Advantage plan preference by checking the box next to your chosen option.
10. Choose a payment method for your monthly plan premium and fill in the necessary details based on your selection.
11. Complete the questions about your health coverage, including other drug coverage and if you have any specific health care conditions like End-Stage Renal Disease.
12. Review the important questions and check the boxes that apply to your eligibility for enrollment periods.
13. Read and agree to the attestation of eligibility. This involves certifying your understanding of the enrollment process and any conditions attached.
14. Finally, sign and date the form. If someone is signing on your behalf, ensure they also provide their information.
15. Once all sections are completed, you may save changes, download, print, or share the form as appropriate to submit your request.

Complete your Enrollment Request Form online today to ensure you receive the health coverage you need.