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Medicare Forms & Fliers
Medicare Advantage Pre-Enrollment Forms
Permission to Contact Form (PDF) - English | Spanish |
Scope of Sales Appointment Confirmation Form (PDF) |
Pre-Enrollment Checklist (PDF) |
2023 Presales Book Service Area 1 (PDF) - English | Spanish |
2023 Presales Book Service Area 2 (PDF) - English | Spanish |
2023 Enrollment Request Form (PDF) - English | Spanish |
2023 Attestation of Eligibility Form (PDF) - English | Spanish |
2023 Summary of Benefits Service Area 1 (PDF) |
2023 Summary of Benefits Service Area 2 (PDF) |
Medicare Advantage Post-Enrollment Forms
Bank Account Withdrawal Pre-Authorization Form (PDF) |
Prescription Claim Form (PDF) |
Appointment of Personal Representative (PDF) |
MedPlus Agent Contracting
Agent/Agency Update Form (PDF) General Agency Use |
General Agency Contacts for New Agents (PDF) |
Consumer Direct Products Independent Contractor Form (PDF) Agent Use |
MedPlus Pre-Enrollment
Replacement of Coverage Form (PDF) |
Broker Acknowledgement Form (PDF) |
Pre-Sales books: |
MedPlus Post-Enrollment
MedPlus Household Discount Request Form (PDF) |
Membership Change Form (PDF) |
Reinstatement Request Form (PDF) |
Authorization for Access to Personal Information (PDF) HIPAA release |
General
Medicare Advantage
Medicare Advantage Supplemental Vendors
Video Visit
|
Nations Hearing
|
SilverSneakers Fitness
|
Blue365 Flier (PDF) |
MedPlus
MedPlus Sales Brochure (DC) (PDF) |
MedPlus Sales Brochure (VA) (PDF) |
MedPlus Sales Brochure (MD) (PDF) |
Medicare & MedPlus 2023 Updates (PDF) |
CareFirst Dental - It's the Right Decision Flier (PDF) |
SilverSneakers Fitness
|
Blue365 Flier (PDF) |