You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit. Your plan will send you a bill for the plan’s premium.If you want to join a plan during fall open enrollment (October 15–December 7), the plan must get your completed form by December 7.The items in Section 2 are optional - you can’t be denied coverage because you don’t fill them out. Note: You must complete all items in Section 1. Your permanent address and phone number.Your Medicare Number (the number on your red, white, and blue Medicare card).Visit to learn more about when you can sign up for a plan. In certain situations where you’re allowed to join or switch plans.Within 3 months of first getting Medicare.Between October 15–December 7 each year (for coverage starting January 1).Important: To join a Medicare Advantage Plan, you must also have both: Be a United States citizen or be lawfully present in the U.S.

People with Medicare who want to join a Medicare Advantage Plan

How to fill out the enrollment form Who can use this form?

Lubbock blue card program