Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form (Page 2 of 8) in pdf

Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form Page 2

2017

Blue MedicareRx

(PDP) Medicare Prescription Drug Plan Individual Enrollment Form

Please contact Blue MedicareRx Value Plus (PDP) or Blue MedicareRx Premier (PDP)

if you need information in another format (Large Print).

To Enroll in Blue MedicareRx (PDP), Please Provide the Following Information:

Please check which plan you want to enroll in:





Blue MedicareRx Value Plus $43.10 per month

Blue MedicareRx Premier $127.70 per month

LAST Name:

FIRST Name:

Middle Initial



Mr.

Mrs.

Ms.

Birth Date:

Sex:

Primary Phone Number:

Alternate Phone Number:



( __ __ /__ __ /__ __ __ __)

(

)

(

)

(M M / D D / Y Y Y

E-mail Address: [Optional] ___________________________________________________________________

Permanent Residence Street Address (P.O. Box is not allowed):

City:

State:

ZIP Code:

Mailing Address (only if different from Permanent Residence Address):

ZIP

Street Address:

City:

State:

Code:

Legal Representative / Appointment of Representative (AOR) / Power of Attorney (POA)

Name [Optional] ____________________________________________________________________________

Phone Number: [Optional] ____________________ Relationship to You [Optional]______________________

Please Provide Your Medicare Insurance Information

Please take out your Medicare card to

complete this section.

 Please fill in these blanks so they

match your red, white and blue

Name:

Medicare card

___________________________________________

- OR -

Medicare Claim Number

Sex

 Attach a copy of your Medicare card

__ __ __ –__ __–__ __ __ __

 M  F

___

or your letter from Social Security or

the Railroad Retirement Board.

Is Entitled To

Effective Date

You must have Medicare Part A or Part B

__ __ –__ __–__ __

HOSPITAL (Part A)

(or both) to join a Medicare prescription

__ __ –__ __–__ __

MEDICAL (Part B)

drug plan.

S2893_1634 Approved 06152016

Blue Medicarerx (Pdp) Medicare Prescription Drug Plan Individual Enrollment Form Page 2

Related Articles

Related forms

Related Categories