Peracare enrollment change form medicare coverage 2012-2026

1. Click ‘Get Form’ to open the PERACare Enrollment/Change Form in the editor.
2. Begin by entering your Social Security Number (SSN) at the top of the form, followed by your last name, first name, middle initial, date of birth, and daytime telephone number.
3. In the signature section, sign and date the form. If you are enrolling or changing coverage for a spouse, ensure they also sign and date.
4. Specify your desired effective date for enrollment or changes in coverage. Note that if this date is not your retirement effective date, additional documentation may be required.
5. Complete the dependent enrollment section if adding coverage for dependents. Ensure all necessary information is filled out accurately.
6. Fill out the Medicare Information section only if enrolling in a health plan or changing plans. Indicate whether you or your dependents have Medicare Part A and/or B.
7. Select your desired health, dental, and vision plans from the options provided on the second page of the form.

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