Medicareblue Rx Individual Change Form Page 4
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6Enrollee name:
E. SIGNATURE:
I want to transfer from my current plan option to the plan option I have selected here. I understand that
my signature (or the signature of the person authorized to act on my behalf under State law where I live)
on this application means that I have read and understand the contents of this change form, including the
information in Section F. If signed by an authorized individual (as described above), this signature certifies
that 1) this person is authorized under State law to complete this enrollment and 2) documentation of
this authority is available upon request by Medicare. The information on this change form is correct to the
best of my knowledge. I understand that if I intentionally provide false information on this form, I will be
disenrolled from the plan.
Your Signature: ______________________________________________ Today’s Date: ____________________
q I give permission to the licensed agent identified below to enter my change form online through
For Authorized Representative Use Only
If you are the authorized representative, you MUST sign above and provide the following information:
Name (Print): _______________________________________ Phone number:
_________________________
Address: ___________________________________________________________________________________________
City: ____________________________________________ State: __________ ZIP Code: ________________________
Relationship to Enrollee: ____________________________________________________________________________
q I want all mail for this member sent to me.
For Agent Use Only
Agent Name (Print): ________________________________________________________________________________
Agent #: ___________________________________ Agency #: _____________________________________________
q Check if you have received this completed enrollment form with the enrollee’s signature from the
enrollee. This paper form must be submitted using one of the methods below within two (2) calendar
days of the date you receive it. Sign and date below when you receive the form from the beneficiary.
Agent signature: ___________________________________________________________________________________
Date form received: _________________________ Phone number:
_________________________________
Check selected submission method and enter information as appropriate:
q Paper to online application. Enter online confirmation number:
__________________________________________________________________________________________________
q Application faxed. Enter date faxed (keep fax confirmation sheet):
__________________________________________________________________________________________________
q Application sent overnight. Be sure to keep the overnight receipt.
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