Medicare Enrollment Appeal Request Form

Medicare Enrollment Appeal Request Form
Use this form to request an appeal related to a Medicare enrollment decision. Please provide complete and accurate information to help us process your appeal.
Full Name
First NameLast Name
Preferred Contact Method
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Medicare Member/Reference Number (last 4 digits only)
Type of Enrollment Issue Being Appealed
If 'Other', please specify the enrollment issue
Brief Description of Appeal Reason
Date Enrollment Decision Was Received
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Upload Supporting Documents (if any)
Cancelof
Should be Empty: