Enroll Now

• MedicareBlue PPO (Regional PPO) Enrollment Form
• MedicareBlue Rx (PDP) Enrollment Form
• When to Enroll

PDF Instructions

You can either print this form and fill it out by hand or open it on your computer and type in the information.

To fill it out by hand:

• Click on the paper form link and print it on your computer.
• Print your information legibly in each section.
• Sign and date the form on page 3.
• Keep a copy for your records.
• If anyone helps you complete your application, that individual must sign the enrollment form and indicate his or her relationship to you.
• Send the original form with your signature to the address listed at the top of the form.

To fill it out on your computer:

• Click on the paper form link to open the form on your computer.
• Use your mouse or tab key to move from one part of the form to the next. Click on a box to check it. Use the tab key to move from one fill-in area to the next, such as from the name fields to Birth Date on the enrollment forms or Member Number on the change form.
• Save it to your computer using “SAVE AS” and giving it a new name. You will not be able to save it to YourMedicareSolutions.com.
• Type your information in each shaded box (click “Highlight Fields” at the top of the form to see the shaded areas you need to complete).
• Once you’ve entered all of your information, print the form.
• Sign and date the form on page 3.
• If anyone helps you complete your application, that individual must sign the enrollment form and indicate his or her relationship to you.
• Keep a copy for your records.
• Send the original form with your signature to the address listed at the top of the form.