Enrollment Request Form - 2017 Page 3
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Information about you.
City
County
State
ZIP Code
Email Address
Go paperless. Get plan materials online.
o
Check here to get plan materials delivered online. It’s an easy and secure way to get information
like your plan documents, benefit statements and wellness information. You may get some
materials in the mail while we work to make them available online. Once you receive an email
notification, go to and use your member ID card to register your
account. Once registered, you can review your materials, benefits, claims and so much more.
You can switch to paper delivery at any time or call us to have a paper copy sent to you.
Information about your Medicare
Please use the information from your red, white and blue Medicare card. Remember, you need
to have Medicare Part A or Part B (or both) to join this plan.
You can simply fill in the blanks so they
match your card.
Or, you can attach a copy of the card or
your letter from Social Security or the
Railroad Retirement Board.
How do you want to pay?
You can pay your monthly premium (including any late enrollment penalty you may owe) by mail or
from your bank account through Electronic Funds Transfer (EFT). You can also choose to pay your
premium by automatic deduction from your Social Security or Railroad Retirement Board benefit
check each month.
This plan has a premium (monthly payment). Please choose how you want to pay it. Note: If you
have a late enrollment penalty (LEP), we’ll add it to your premium.
If you don’t choose an option, we’ll send a bill each month to your mailing address.
¨ I want to pay directly from my bank account.
Please attach a blank check from the account you’d like to use. Write “VOID” across the front.
·
Please DO NOT send a deposit slip or money order.
Enrollee Name
PDEX17PD3877053_000
Y0066_160609_110859 Approved
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Parent category: Medical