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

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1, where you will need to provide your Group number and Subscriber number. Ensure these are accurate to avoid delays.
In Section 2, select the Application type. If applicable, indicate your special enrollment reason and provide the date of the event.
Proceed to Section 3 for Employee information. Fill in all required fields marked with an asterisk, including your name, Social Security number, mailing address, and date of birth.
In Section 4, list any dependents you wish to enroll. Complete all fields for each dependent, ensuring that names and dates of birth are correct.
Section 5 asks about other insurance coverage. Answer truthfully as this may affect your eligibility.
Finally, review Section 8 for authorization. Sign and date the form before submission to confirm that all information is accurate.

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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).

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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.

What happens if you dont enroll in Medicare Part A at 65?

Part A late enrollment penalty If you have to buy Part A, and you dont buy it when youre first eligible for Medicare, your monthly premium may go up 10%. Youll have to pay the penalty for twice the number of years you didnt sign up.

Is a person automatically enrolled in Medicare at age 65?

It depends. If youre receiving benefits from Social Security or the Railroad Retirement Board (RRB) at least four months before you turn 65, you do NOT need to sign up; youll automatically get Part A and Part B starting the first day of the month that you turn 65.

What are the 3 requirements for Medicare?

Be age 65 or older; Be a U.S. resident; AND. Be either a U.S. citizen, OR. Be an alien who has been lawfully admitted for permanent residence and has been residing in the United States for 5 continuous years prior to the month of filing an application for Medicare.

Enrollment application & change of information form - Moda Health 2026

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