Maryland 65 application 2026

1. Click ‘Get Form’ to open the Maryland 65 application in the editor.
2. Begin by filling out Section 1, Applicant Information. Enter your last name, first name, middle initial, and residence address. Ensure all information is printed clearly.
3. In Section 1B, select the MediGap-65 Plan you are applying for by checking only one box. Review your options carefully.
4. Proceed to Section 2 and provide your Medicare coverage information as it appears on your Medicare card. This includes your Health Insurance Claim Number and effective dates for both Part A and Part B.
5. Complete Section 3 regarding eligibility. Answer all questions truthfully to ensure a smooth processing of your application.
6. If applicable, fill out Section 4 for health evaluation. Answer each question with 'Yes' or 'No' as required.
7. Review all sections for accuracy before signing at the end of the document. Once completed, submit your application using the provided postage-paid envelope or mail it directly.

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