Get Nc Blue Cross D168 2013

Completing the NC Blue Cross D168 online enrollment form is an essential step for those seeking coverage under the Medicare Prescription Drug Plan. This guide will provide you with clear, step-by-step instructions to ensure that you accurately fill out the form and submit it successfully.

Follow the steps to complete your enrollment form effectively.

1. Click the ‘Get Form’ button to access the enrollment form and open it in your preferred document editor.
2. Provide your personal information in Section A. This includes your first name, middle initial, last name, and any suffix (e.g., Jr., Sr.), as well as your sex, home phone number, and permanent residence address. Ensure that the street address is not a P.O. Box and that all fields are filled accurately.
3. Enter your birth date in the format MM/DD/YYYY, followed by your city, state, county, and zip code. If you have an alternate phone number, you may provide it as an optional detail.
4. If your mailing address differs from your permanent residence address, fill in the corresponding fields for your mailing address, including city, state, and zip code.
5. Complete the emergency contact information if desired, providing the relationship to you and their phone number.
6. In Section B, choose the plan you wish to enroll in by checking either the 'Blue Medicare Rx Enhanced' or 'Standard' box. Note the associated premium costs to make an informed choice.
7. In Section C, provide your Medicare insurance information. Take out your Medicare card and fill in the Medicare Claim Number, indicating your entitlement to hospital (Part A) or medical (Part B) services.
8. Proceed to Section D to select your payment method for the plan premium. You may choose between receiving a bill each month or opting for automatic deductions from your Social Security or Railroad Retirement Board benefit check.
9. Answer the eligibility question in Section E regarding other drug coverage. If applicable, list the other coverage details and identification numbers.
10. Review Section F and check any applicable boxes that confirm your eligibility for an enrollment period. Ensure to fill in any required effective dates.
11. In Section G, read the applicant agreement thoroughly and provide your signature, the date, and, if necessary, the details of the authorized representative.
12. Review all filled sections for accuracy, save your changes, and then download, print, or share the completed document as needed.

Begin filling out your NC Blue Cross D168 form online to ensure your Medicare coverage today.