KelseyCare Advantage Form

To enroll in KelseyCare Advantage, please provide all the requested information in the form below, sign, and click submit when done.

Please check the plan you are enrolling in:*

KelseyCare Advantage Preferred Rx $100.00 per month

County of Residence*

Last Name*

First Name*

Middle Intial

Title*

Mr.
Mrs.
Ms.

Birth Date:*

Sex*

M
F

Home Phone Number:*

Alternate Phone Number

Permanent Residence Street Address (P.O Box is not allowed)*

City*

State*

Zip code*

Mailing Address (Only if different from your Permanent Resident Address)

City

State

Zip code

Email*

Please Provide Your Medicare Insurance Information as it appears on your card.

Name (as it appears on your Medicare Card)*

Medicare Number*

You must have Medicare Part A and Part B to join a Medicare Advantage plan.

HOSPITAL (Part A)*

MEDICAL (Part B)*

Please attach a copy of your Medicare Card showing Part A and B.

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 512 MB.

Please read and answer these important questions

Do you have End-Stage Renal Disease (ESRD)*

Yes
No

If you have had a successful kidney transplant and/or you don't need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don't need dialysis, otherwise we may need to contact you to obtain additional information.

Upload a note or record from your doctor

Accepted file types: jpg, jpeg, png, pdf, Max. file size: 512 MB.

Will you have other prescription drug coverage in addition to KelseyCare Advantage?*

Yes
No

Name of other coverage*

ID for this coverage*

Group # for this coverage*

Are you a resident in a long-term care facility, such as a nursing home?*

Yes
No

Name of Institution*

Address of Institution*

Phone number of Institution*

Are you enrolled in your State Medicaid program?*

Yes
No

Medicaid number*

Do you or your spouse work?*

Yes
No

Please check one of the boxes below if you would prefer us to send you information in language other than English or in an accessible format:

Spanish
Braille
Large Print
Other

Other language type

Signature*

Today's Date*