Get Medicare Preferred Standard (ppo) Individual Enrollment Request Form — 2013

Completing the Medicare Preferred Standard (PPO) Individual Enrollment Request Form online is a crucial step in gaining access to health benefits. This guide offers clear instructions to help users navigate each section of the form effectively.

Follow the steps to complete the enrollment form.

1. Press the ‘Get Form’ button to obtain the form and open it in a viewer.
2. Begin by filling out your personal information, including your last name, first name, middle initial, contact numbers, birth date, and sex. Ensure all details match your identification documents.
3. Provide your permanent residence address. Note that P.O. boxes are not acceptable. If you have a different mailing address, fill that in as well.
4. Indicate your preference for receiving health-related communications via email. If desired, enter your email address to be informed about future electronic documents.
5. Next, input your Medicare insurance information. Use your Medicare card to complete the section accurately, including your name and Medicare claim number.
6. Select your payment option for the monthly plan premium. Choose between receiving a monthly bill or opting for automatic deductions from your bank account or Social Security benefits.
7. Answer the important health questions regarding conditions such as end-stage renal disease, existing drug coverage, and residency in long-term care facilities.
8. Carefully review and check the boxes that confirm your eligibility for an enrollment period.
9. Sign the authorization section to certify the accuracy of your information and agree to the terms. Include the date of your signature.
10. If applicable, fill out the authorized representative's information. Ensure all fields in this section are completed.
11. Save your changes, then download or print the completed form. Finally, submit the form via mail or fax as instructed.

Start filling out your Medicare Preferred Standard (PPO) enrollment form online today.