What is your current Medicare number?

When you enter your Medicare number below, your Medicare eligibility will be verified using data from the Centers for Medicare & Medicaid Services (CMS). If you are not currently eligible for Medicare, your application may be denied.

This is an 11 digit number

Personal Information

What is your primary address?

What is your phone number?

This is a 10-digit number.

This is a 10-digit number.

Preferred Language

Race and Ethnicity

Sharing this information helps the U.S. Department of Health & Human Services continue to measure and ensure fair access to coverage for everyone with Medicare. You cannot be denied coverage if you choose not to answer.​

Tell us about your current doctor and clinic.

Name of Primary Care Physician (PCP)

Name of Clinic

Health Center

By clicking the 'Agree' button below, I agree and understand that:

• I am enrolling in
  Elderplan Extra Help(HMO-POS)
  Elderplan Flex(HMO-POS) Plan
  the Medicaid Beneficiaries (HMO-POS D-SNP) Plan
• To stay in Elderplan, I must keep both Hospital (Part A) and Medical (Part B).
• By joining this Medicare Advantage (MA) Plan, I acknowledge that Elderplan will share my information with Medicare, who may use it to track my enrollment, make payments, and for other purposes allowed by Federal law that authorize collecting this information (see Privacy Act Statement below).
• I understand that I can be enrolled in only one MA plan at a time - and that enrollment in this plan will automatically end my enrollment in another MA plan (exceptions apply for MA PFFS and MA MSA plans).
• I understand that when my Elderplan coverage begins, I must get all my medical and prescription drug benefits from Elderplan. Benefits and services provided by Elderplan and contained in my Elderplan "Evidence of Coverage" document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Elderplan will pay for benefits or services that are not covered.
• The information on this enrollment form is accurate to the best of my knowledge. I understand that if I knowingly provide false information on this form, I will be disenrolled from the plan.
• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (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.
• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

If I sign as an authorized representative, it means I have the legal right under state law to sign.

Electronic Signature

Please type your name as your electronic signature.

Please review your application before submitting.

When you click "Submit application" below you are providing your e-signature (or the e-signature of your authorized representative). If signed by an authorized representative (as described above), this e-signature certifies that:

1. This person is authorized under the laws of the state where you live to complete this enrollment and
2. Documentation of this authority is available upon request from Medicare.

It means that you have read and understood the information on this form.

Please note that once you submit your application, you will no longer be able to make edits online.

By submitting your enrollment application, you are:

• Providing your electronic signature
• Submitting your enrollment application electronically
• Consenting to online contracting through the Internet
• Consenting to receive future communications from us online through the Internet, including mail
• Offering to purchase a product from Elderplan
• Acknowledging and agreeing with the above statements

You will not be enrolled until your application has been reviewed and accepted.