Medicare Plan Enrollment Form 2026

1. Click ‘Get Form’ to open the Medicare Plan Enrollment Form in our editor.
2. Begin by filling out your personal information, including your Employee ID, First Name, Last Name, and Contact Number. Ensure you use blue or black ink if printing.
3. Indicate your gender and address. If there is a change in your address, check the corresponding box.
4. In Section A, select the Medicare Advantage Plan for yourself and any eligible dependents. Make sure to complete this section for each person being covered.
5. Proceed to Section B to provide your Medicare information as it appears on your Medicare card. Attach a copy of the card if required.
6. Answer all questions in Section C regarding Medicare-related queries accurately to ensure proper enrollment.
7. Review all sections for completeness and accuracy before submitting the form through the Secure Document Portal.

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