Online Enrollment Form

Be advised that:

You may be able to enroll in or make changes to your Medicare Advantage plan outside of the regular enrollment period if you qualify for a Special Enrollment Period (SEP).  Certain life events can trigger an SEP such as changes to your Medicaid eligibility, moving outside your plan's service area, or other qualifying circumstances.

 If you qualify, your new coverage typically begins the first day of the month after your request.  You may also have an option to make changes during the Annual Enrollment Period and Medicare Advantage Open Enrollment.

If you think you might qualify for a special enrollment period, contact us to learn more about your options.

Who can use this form?

People with Medicare who want to join a Medicare Advantage Plan.

To join a plan, you must:

  • Be a United States citizen or be lawfully present in the United States.
  • Live in the plan's service area.

Important: To join a Medicare Advantage Plan, you must also have both:

  • Medicare Part A (hospital insurance).
  • Medicare Part B (medical insurance).

When do I use this form?

You can join a plan:

  • Between October 15 – December 7 each year (for coverage starting January 1).
  • Within three months of first getting Medicare.
  • In certain situations where you're allowed to join or switch plans.

Visit www.medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

  • Your Medicare number (the number on your red, white, and blue Medicare card).
  • Your permanent address and phone number.

Note: You must complete all items in section 1. The items in section 2 are optional — you can't be denied coverage because you don't fill them out.

Reminders:

  • 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.
  • Your plan will send you a bill for the plan's premium. 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.

What happens next?

Send your completed and signed form to:

Keystone First VIP Choice
P.O. Box 7137
London, KY 40742-9732

Once they process your request to join, they'll contact you.

How do I get help with this form?

Call Keystone First VIP Choice at 1-855-241-3648 TTY users can call 711.
Or call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

En español: Llame a Keystone First VIP Choice al 1-855-241-3648/711 (TTY).
O a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.

Individuals experiencing homelessness

If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., Social Security Checks) may be considered your permanent residence address.

If you need help filling out the online enrollment form, use our step-by-step online form instructions.

We will send you a notice in the mail to let you know if your enrollment to Keystone First VIP Choice is approved or denied.

Y0093_001_243582929