• Medicare Advantage Plan Enrollment Eligibility Questionnaire Form

    Complete this Medicare Advantage Plan Enrollment Eligibility Questionnaire Form to help determine if you appear eligible to enroll in a Medicare Advantage plan.
  • What is your date of birth?*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Do you currently have Medicare Part A and Part B?*
  • Are you a U.S. citizen or a legal resident for at least 5 consecutive years?*
  • Are you currently enrolled in another Medicare Advantage plan?*
  • Do you have any other health insurance coverage in addition to Medicare?*
  • Do you require assistance with daily living activities (such as bathing, dressing, or eating)?*
  • Should be Empty:
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