Enrollment application & change of information form - Moda Health: Fill out & sign online

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

The best way to modify Enrollment application & change of information form - Moda Health online

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

With DocHub, making changes to your documentation requires just a few simple clicks. Follow these quick steps to modify the PDF Enrollment application & change of information form - Moda Health online for free:

Sign up and log in to your account. Sign in to the editor with your credentials or click on Create free account to test the tool’s features.
Add the Enrollment application & change of information form - Moda Health for editing. Click the New Document option above, then drag and drop the file to the upload area, import it from the cloud, or via a link.
Alter your file. Make any changes required: insert text and pictures to your Enrollment application & change of information form - Moda Health, highlight details that matter, remove sections of content and replace them with new ones, and add symbols, checkmarks, and fields for filling out.
Finish redacting the template. Save the updated document on your device, export it to the cloud, print it right from the editor, or share it with all the parties involved.

Our editor is super intuitive and efficient. Try it out now!

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Contact us

How do I enroll in Medicare for the first time?

Apply online (at Social Security) This is the easiest and fastest way to sign up and get any financial help you may need. Youll need to create your secure my Social Security account to sign up for Medicare or apply for Social Security benefits online. Call 1-800-772-1213. TTY users can call 1-800-325-0778.

What does enrollment application mean?

Enrollment Application means the information submitted by or on behalf of an individual to the Exchange in connection with a request to enroll as either a Subscriber or Dependent.

Who can complete an enrollment application on behalf of a participant?

To complete an Enrollment Application on behalf of a consumer, what authority must the individual have? The individual must be legally authorized in the state in which the consumer resides to act on behalf of the consumer (e.g., Power of Attorney).

What forms are needed for Medicare Part B?

You can complete form CMS-40B (Application for Enrollment in Medicare Part B [Medical Insurance]) and CMS-L564 (Request for Employment Information) online. You can also fax the CMS-40B and CMS-L564 to 1-833-914-2016; or return forms by mail to your local Social Security office.

Can you get Medicare immediately?

You can sign up for Part A any time after you turn 65. Your Part A coverage starts 6 months back from when you sign up or when you apply for benefits from Social Security (or the Railroad Retirement Board). Coverage cant start earlier than the month you turned 65.

Related forms

be ready to get more