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Click ‘Get Form’ to open the Top Forms and PublicationsETF in the editor.
Begin by entering your Medicare information. Ensure that you include your Medicare number and effective dates for both Hospital (Part A) and Medical (Part B) sections. If you do not have a Medicare card yet, write 'none' in the appropriate field.
List all persons insured under your group health insurance policy. Fill in their names, eligibility reasons (age, disability, ESRD), and corresponding Medicare details clearly.
Indicate whether you will use the state’s Navitus MedicareRX plan by selecting 'Yes' or 'No', and if applicable, specify your chosen plan.
Complete the signature section by providing your printed name, date, telephone number, mailing address, and member ID or SSN. Ensure that you sign the form as required.
Attach a copy of your Medicare card or relevant documentation before submitting the form via mail or fax to ETF.

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Versions	Form popularity	Fillable & printable
2024	4.1 Satisfied (56 Votes)
2020	4.1 Satisfied (47 Votes)
2014	4.9 Satisfied (59 Votes)

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