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Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

BlueJourney Alliance (HMO SNP)

CBC Medicare PPO Redirect

PLAN SELECTION AND APPLICANT INFORMATION: Step 1 of 5

Guidelines:

  • Choose your plan.

  • Enter your name as it appears on your Medicare ID Card.

  • If your mailing address is different from your home address, please enter it under 'Mailing Address'.

  • Enter your date of birth as MM/DD/YYYY.

  • If a Power of Attorney or Guardian is completing this application, please complete Section 5. Enter your address, phone number and relationship to the enrollee.

  • If a legal representative signs the form for the applicant, any of the following documents must be available if requested by the plan or by the Centers for Medicare and Medicaid services, which is the federal agency that administers Medicare.

    • Court order appointing the representative as legal guardian

    • Durable power of attorney for healthcare decisions

    • Proof of other authorization required by state law that empowers the individual to effect an election on behalf of the applicant

Required fields are noted with an asterisk *.

Personal Information

    I do not have an email address.
Permanent Residence Address (P.O. Box is not allowed)
Mailing Address (only if different from your permanent residence address)

Medicare beneficiaries may also enroll in BlueJourney Alliance (HMO SNP) through CMS Medicare Enrollment Center located at http://www.medicare.gov.

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Updated February 10, 2020

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