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Anthem Medicare Preferred (PPO) Individual Short Enrollment Request Form

Anthem Medicare Preferred (PPO) Individual Short Enrollment Request Form 2025

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The document is an Individual Short Enrollment Request Form for the Anthem Medicare Preferred (PPO) Medicare Advantage Plan, intended for individuals changing their existing plan. It provides instructions for completing and submitting the form, details about payment options for premiums, and information regarding assistance available in Spanish. The form requires personal information from the applicant and includes sections for authorizing deductions from bank accounts or Social Security benefits. It emphasizes the importance of accurate information and outlines the consequences of providing false information.

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