Use these step-by-step instructions to fill out the enrollment form.

Enrollment form

• Go to the enrollment form page.
• Enter your ZIP code in the box.
• Click Go To Enrollment Form.

Choose a plan

• Pick the Medicare Advantage plan you want to join.

Personal information

• Provide the personal information requested. Please contact Keystone First VIP Choice (HMO-SNP) if you need information in another language or format (such as Braille).

Medicare insurance information

• You will need your Medicare card to complete this section.

Important questions

• Please answer all six questions in this section.

Select a primary care physician (PCP), clinic, or health center from our provider network

• To find a PCP, click Please Choose a Primary Care Physician. This will take you to the Online Provider Directory. Use this tool to find a PCP in your area.
• To choose a PCP, click on the name of the doctor you want to use. The name will be automatically filled in on your application form.
• Need help? Call 1-855-241-3648 (TTY 711), seven days a week, 8 a.m. to 8 p.m.

Authority to sign application

Please check the circle next to the statement that applies to you.

Submit enrollment form

• Click Enroll Now to send in your enrollment form.
• You will receive a confirmation number that we have received your form. Please make a note of this number for your reference.
• Once your enrollment is accepted by the Centers for Medicare & Medicaid Services (CMS), we will send your new member materials, including your Keystone First VIP Choice member ID card.

If you need help

Call 1-855-241-3648 (TTY 711), Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31.