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DHS-4106C-ENG (Health plan enrollment form for people 65 or ... 2026
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- Click ‘Get Form’ to open the DHS-4106C-ENG in the editor.
- Begin by filling out your personal information in the 'Enrollee Information' section. Ensure that your last name, first name, middle initial, date of birth, gender, and contact details are accurate.
- Indicate whether you live in a long-term care facility and verify your Medicare information. If there are discrepancies, correct them directly in the form.
- Answer the important health questions regarding end-stage renal disease and other health coverage. Provide details about any additional insurance if applicable.
- Select your preferred health plan by checking one of the boxes provided. If you wish to enroll in Minnesota Senior Health Options (MSHO), ensure to check that box as well.
- Review all filled sections for accuracy before signing at the bottom of the form. Make sure to include the date and any required representative information if applicable.
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What is the name of the United States government health insurance program for people age 65 or older?
This enrollment form allows individuals to apply for group health and dental coverage. Its designed for employees to provide necessary personal information, dependent details, and coverage choices.
What is the federal health insurance for people over 65?
Medicare is the Federal health insurance program for people 65 years of age or older.
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