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Medicare Eligibility Statement - Wisconsin Department of 2026
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- Click ‘Get Form’ to open the Medicare Eligibility Statement in the editor.
- Begin by entering your personal information, including your name, telephone number, and mailing address. Ensure that all details are accurate and legible.
- In the section for 'All Persons Insured Under Your Group Health Insurance Policy', list everyone covered under your plan. For each individual, provide their Medicare number and effective dates for both Hospital (Part A) and Medical (Part B).
- Indicate whether you will use the state’s Navitus MedicareRX plan by selecting 'Yes' or 'No'. If you choose 'No', specify which plan you will use.
- Sign and date the form at the bottom. Make sure to attach a copy of your Medicare card or any relevant documentation before submitting.
- Once completed, save your document and return it via mail or fax to ETF as instructed.
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