Use the step-by-step instructions included with the

Individual Enrollment Request Form/Attestation (PDF).

Personal information

• Provide the personal information requested.

Medicare insurance information

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

Important questions

• Please answer all five questions in this section.

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

• To find a PCP, use our online provider directory or call Member Services at 1-800-450-1166 (TTY 711), 8 a.m. – 8 p.m., Monday through Friday, from April 1 to September 30. From October 1 to March 31, 8 a.m. – 8 p.m., seven days a week.
• Once you've selected a PCP, write the PCP's name and provider number on your enrollment form.

Your signature

• Please read the information provided, then sign and date your enrollment form.

Mail the forms to:

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

• If you are an authorized representative, please provide the information requested.
• Once your enrollment is accepted by the Centers for Medicare & Medicaid Services (CMS), we will send you member materials, including your Keystone First VIP Choice (HMO-SNP) member ID card.

If you need help

Do you need help filling out the enrollment form? Do you have questions about enrolling in Keystone First VIP Choice (HMO-SNP)?

Call us at 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.