Step 1: My Application
Step 2: Eligibility
Medicare Advantage Plan
Plan Name
First Name
Middle Name (optional)
Last Name
Sex
Please select one...
Female
Male
Prefer Not to Answer
Title (optional)
Please select one...
Mr.
Mrs.
Ms.
Date of Birth (MM/DD/YYYY)
Street Address
City
State
Zip Code
Phone Number
Email Address
Next: Eligibility
Medicare Information
Medicare Number
Hospital (Part A) start date (optional)
Medical (Part B) start date (optional)
Eligibility Questions
Will you have other prescription drug coverage (like VA, TRICARE) in addition to this plan for which you are applying?
Please select one...
Yes
No
Which statement best applies to you?
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I am new to Medicare
I qualify for a Special Enrollment Period (SEP)
Are you enrolled in your State Medicaid program? (optional)
Please select one...
Yes
No
Are you a resident in a long-term care facility, such as a nursing home? (optional)
Please select one...
Yes
No
Do you have health insurance with an employer or union right now? (optional)
Please select one...
Yes
No
Physician Information (Optional)
Primary Care Physician Full Name (optional)
Primary care physician ID number? (optional)
Primary care physician phone number (optional)
Are you now seeing or have you recently seen this doctor? (optional)
Please select one...
Yes
No
More Eligibility Questions (Optional)
Once enrolled, will you or your spouse work? (optional)
Please select one...
Yes
No
How would you like to pay your premium? (optional)
Please select one...
Get a Monthly Bill
Social Security benefit check deduction (SSA),
Railroard Retirement Board benefit deduction (RRB)
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