Enrollment Form Lead Intake, Application, or Annual Review Form Purpose of call* Lead Intake Application Annual Review Start Call Recording*Read disclosure at beginning of phone recording: "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all your options." Call Recorded Recording Skipped Explain reason recording skipped*Valid reasons include face-to-face meeting, communicated via email, client self-enrollment, etc.Client Name* Client Information/NotesDOB, Zip Code, Phone number, Email address, Gender, Part A/B Eff dates, etc.Will PDP or MAPD be discussed with client? Yes No Scope of AppointmentThis Scope of Appointment documents that you agree to discuss Medicare Part D plans and/or Medicare Advantage plans with a licensed agent. Please note that the person who will discuss these Medicare plans is contracted by insurance companies and Medicare plans. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. This agreement does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. I wish to discuss the following types of products: Part D plans Medicare Advantage Plans If client agrees to SOA disclosure, input client initials. Has client been satisfied with their current plan(s), any notes on plan?This year there are some new optional supplemental riders available, is this something you'd be interested in discussing? Yes No Available riders to discuss Dental/Vision Insurance Final Expense - Lump Sum Life Insurance Cancer - Lump Sum Cancer Insurance Heart Attack and Stroke - Lump Sum Heart Attack/Stroke Insurance Home Care Plus Hospital Indemnity Recovery Care Sale(s) Description*List carrier, name of plan, proposed effective date, premium and any policy fee. If multiple sales (ie Medsup and PDP) include both entries.Enrolling in (select all that apply)* Medsup PDP Medicare Advantage Dental/Vision Cancer Heart Attack and Stroke Final Expense - Lump Sum Life Other (include in Sale Description section) Applying in which state?* Alabama Arizona Arkansas California Colorado Florida Georgia Hawaii Idaho Illinois Maryland Michigan Minnesota Missouri Montana Nevada New Jersey New York North Carolina Oregon Pennsylvania South Carolina Tennessee Texas Virginia Washington Wisconsin Wyoming Other (confirm agency appointment in state) First Name*First name as it appears on Medicare card Middle InitialMiddle initial (if any) as it appears on Medicare card Last Name*Last name as it appears on Medicare card Birthdate*Date of Birth Month Day Year Gender* Male Female Phone*Phone numberEmail*Email address Address*Residence Street Address (no PO Box) UnitUnit or Apt # City*City of Residence County*County of Residence State*State of Residence Zip Code*Residence Zip Code Have a Preferred Mailing Address Different than Residence?* Yes No Mailing AddressPreferred Mailing Address Mailing UnitUnit or Apt # Mailing CityMailing Address City Mailing StateState of Mailing Address Mailing Zip CodeMailing Zip Code Did you run an Rx report?* Yes No Why was an Rx report not required?* Client confirmed no prescriptions Other (explain in Sales Description) Medsup Enrollment type* Initial Enrollment Period Guaranteed Issue Underwritten Reason for Medsup Guaranteed Issue*For example, lost coverage, moved, MAPD trial period, etc. Remind Client to provide GI ProofThis can include MAPD card for plan that is ending, termination letter from carrier, etc. Remind client that carrier will call with UW questionsMedsup Carrier*CarrierAetnaAmerican Retirement - CignaAnthem Blue CrossBlue Cross Blue Shield MontanaBlue Shield of CaliforniaCignaContinental Life - AetnaHumanaLoyal American - CignaMutual of OmahaTransamericaUnited AmericanUnitedHealthcareUnited of OmahaOther (include in Sale Description)Medsup Plan Type*PlanPlan FPlan F High DeductiblePlan GPlan G High DeductiblePlan NOther (specify in Sales Description section)Medsup Premium Amount (not including any HH discount)* Do you have a spouse?*Household discounts may apply Yes No Name of spouse* Spouse Date of Birth* Month Day Year Spouse Notes: particularly for use in HH discount determinationspouse SSN, spouse Medsup carrier, spouse AARP #, etc. Household Discount?* Yes No Is there a Policy Fee?* Yes No Policy fee amount* Total Initial Premium with Policy Fee and HH Discount Total Initial Premium with Policy Fee Total Premium with Household Discount Tobacco in last 12 months?* Yes No Tobacco in last 12 months?* Yes No Tobacco in last 12 months?* Yes No Tobacco in last 12 months?* Yes No Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* Tobacco Rates Will Apply. What is monthly Medsup premium for tobacco?* PDP Enrollment type* IEP - Initial Enrollment Period (new to Medicare) IEP2 - Aging in (Turning 65 and eligible for Medicare prior to age 65) AEP - Annual Enrollment Period (Oct 15 - Dec 7) SEP - Special Enrollment Period Reason For SEP* Loss EGHP Change in residence OEP - disenrolling from MAPD Institutionalized Invol Loss Creditable Cvg SEP 65 (joined MAPD T65 and leaving) Medigap trial period (dropped Medigap for MAPD) Reminder: LEP letter due to EHGP PDP Carrier*CarrierAetnaBlue Shield of CaliforniaHumanaMontana Blue Cross Blue ShieldSilverscriptUnited HealthcareWellcareAetna PDP Plan Type*Other (List in Sales Description)Humana PDP Plan Type*Humana Basic Rx PlanHumana Premier Rx PlanHumana Walmart Value Rx PlanOther (list in Sales Description)Blue Shield PDP Plan Type*Blue Shield Rx PlusBlue Shield Rx EnhancedOther (list in Sales Description)Montana BCBS PDP Plan Type*Montana BCBS - MedicareBlue Rx PremierMontana BCBS - MedicareBlue Rx StandardSilverscript PDP Plan Type*SilverScript ChoiceSilverScript PlusSmartRxOther (list in comments)United Healthcare PDP Plan Type*AARP MedicareRx PreferredAARP MedicareRx Saver PlusAARP MedicareRx WalgreensOther (provide info in description)Wellcare PDP Plan Type*WellCare ClassicWellCare Medicare Rx SaverWellCare Medicare Rx SelectWellCare Medicare Rx Value PlusWellcare Value ScriptWellCare Wellness RxPDP Premium*PDP Quoted Premium Amount MedAdv Enrollment type*What is the client's Election Period? IEP - Initial Enrollment Period (New to Medicare) IEP 2 - Aging In (turning 65 and eligible for Medicare prior to age 65) ICEP - Delayed Part B enrollment (eff date BEFORE Part B) AEP - Annual Enrollment Period (Oct 15- Dec 7) SEP - Special Enrollment Period OEP - MAPD Open Enrollment Period Switch (Jan 1-Mar 31) OEPI - Institutionalized Reason for MedAdv SEP* Change in Residence Loss of EGHP Invol Loss Creditable Cvg Contract termination Weather related emergency Medicare Advantage Carrier*CarrierAetnaAlignmentAnthemBlue Shield of CaliforniaHumanaMontana Blue Cross Blue ShieldUnited HealthcareWellCareAetna MedAdv Plan Type*Aetna Medicare Choice Plan (HMO-POS)Aetna Medicare Choice Plan (PPO)Aetna Medicare Choice II Plan (PPO)Aetna Medicare DMG Prime (PPO)Aetna Medicare Eagle Plan (HMO)Aetna Medicare Eagle Plan (PPO)Aetna Medicare Plus Plan (HMO)Aetna Medicare Plus Plan (PPO)Aetna Medicare Premier (PPO)Aetna Medicare Premier Plus (PPO)Aetna Medicare Prime Plan (HMO)Aetna Medicare Prime Plan (HMO-POS)Aetna Medicare Select Plan (HMO)Aetna Medicare Summit Select (HMO)Aetna Medicare Value Plan (HMO)Aetna Medicare Value (PPO)Other (list in Sales Description)Alignment MedAdv Plan Type*AllCare Preferred Plan (HMO)AVA (HMO)CalPlus (HMO)My Choice (HMO)My Choice (PPO)Platinum (HMO)smartHMO (HMO)Other (list in Sales Description)Anthem MedAdv Plan Type*Anthem MediBlue Access (PPO)Anthem MediBlue Connect Plus (HMO)Anthem MediBlue Coordination Plus (HMO)Anthem MediBlue Extra (HMO)Anthem MediBlue Plus (HMO)Anthem MediBlue Select (HMO)Anthem MediBlue StartSmart Plus (HMO)Anthem MediBlue Value Plus (HMO)Other (list in Sales Description)Blue Shield MedAdv Plan Type*65 Plus (HMO)65 Plus Plan 2 (HMO)AdvantageOptimum (HMO)Coordinated Choice (HMO)Inspire (HMO)Promise Coordinated Choice (HMO)Vital (HMO)Other (list in Sales Description)Humana MedAdv Plan Type*HumanaChoice (PPO)HumanaChoice (Regional PPO)Humana Gold Choice (PFFS)Humana Gold Plus (HMO)Humana Honor (HMO)Humana Value Plus (HMO)Other (list in Sales Description)Montana BCBS MedAdv Plan Type*Blue Cross Medicare Advantage Choice Plus (PPO)Blue Cross Medicare Advantage Classic (PPO)Blue Cross Medicare Advantage Flex (PPO)Blue Cross Medicare Advantage Optimum (PPO)Other (list in Sales Description)United Healthcare MedAdv Plan Type*AARP Medicare Advantage Choice (PPO)AARP Medicare Advantage Choice Essential (Regional PPO)AARP Medicare Advantage Choice Plan 2 (Regional PPO)AARP Medicare Advantage Freedom Plus (HMO-POS)AARP Medicare Advantage Patriot (HMO)AARP Medicare Advantage Plan 1 (HMO-POS)AARP Medicare Advantage Plan 2 (HMO)AARP Medicare Advantage SecureHorizons Focus (HMO)AARP Medicare Advantage SecureHorizons Essential (HMO)AARP Medicare Advantage SecureHorizons Plan 1 (HMO)AARP Medicare Advantage SecureHorizons Plan 2 (HMO)AARP Medicare Advantage SecureHorizons Premier (HMO)AARP MedicareComplete (HMO)AARP MedicareComplete Plan 1 (HMO)AARP MedicareComplete Plan 2 (HMO)AARP MedicareComplete Choice (PPO)AARP MedicareComplete Choice Plan 2 (Regional PPO)AARP MedicareComplete Choice Essential (Regional PPO)AARP MedicareComplete Premier (HMO)AARP MedicareComplete SecureHorizons (HMO)AARP MedicareComplete SecureHorizons Essential (HMO)AARP MedicareComplete SecureHorizons Plan 1 (HMO)AARP MedicareComplete SecureHorizons Plan 2 (HMO)AARP MedicareComplete SecureHorizons Plan 3 (HMO)AARP MedicareComplete SecureHorizons Plan 4 (HMO)AARP MedicareComplete SecureHorizons Premier (HMO)AARP MedicareComplete SecureHorizons Value (HMO)Erickson Advantage Freedom (HMO-POS)Erickson Advantage Liberty without Drugs (HMO)Erickson Advantage Signature with Drugs (HMO-POS)Medica HealthCare Plans MedicareMax (HMO)Care Improvement Plus Medicare Advantage (Regional PPO)Preferred Choice (HMO)Sharp SecureHorizons Plan by UnitedHealthcare (HMO)UnitedHealthcare Medicare Advantage Assure (HMO)UnitedHealthcare Medicare Advantage Choice (Regional PPO)UnitedHealthcare MedicareDirect Essential (PFFS)UnitedHealthcare MedicareDirect Rx (PFFS)UnitedHealthcare Medicare Focus (HMO)Other (list in Sales Description)WellCare MedAdv Plan Type*WellCare Best (HMO)WellCare Dividend Prime (HMO)WellCare Elite (HMO)WellCare Plus (HMO)WellCare Premier (PPO)WellCare Prime (PPO)Other (list in Sales Description)MedAdv Plan ID Number* This number can be found via the quoting tool.MedAdv Quoted Premium Amount* Cancer Insurance Carrier*AetnaOther (provide in descriptionFinal Expense Insurance Carrier*AetnaOther (provide in descriptionHeart Attack/Stroke Insurance Carrier*AetnaOther (provide in descriptionCancer Insurance Lump Sum Amount* $5K $10K $15K Final Expense Lump Sum Benefit Amount* Heart Attack/Stroke Insurance Lump Sum Amount* $5K $10K $15K Cancer Recurrence Benefit add-on? Yes No Final Expense Plan Selection:* Graded Benefit Level Benefit Modified Benefit Heart Attack/Stroke Recurrence Benefit add-on? Yes No Cancer Insurance Quoted Premium Amount* Final Expense Insurance Quoted Premium Amount* Heart Attack/Stroke Insurance Quoted Premium Amount* In the past 10 years have you been treated for or diagnosed with AIDS or HIV? Yes No Currently hospitalized, in a nursing facility, confined to a bed, or receiving hospice care?* Yes No Require use of oxygen for any lung or respiratory disorder?* Yes No Diagnosed to have an aneurysm that has not been surgically repaired?* Yes No Tested positive for HIV or AIDS?* Yes No At any time have you been diagnosed, treated or had surgery for any of the following:*-bone marrow, stem cell or organ transplant -kidney disease requiring dialysis -Alzheimer's, dementia, mental incapacity -Lou Gehrig's Disease (ALS) -Life expectancy 12 months or less Yes No Do you have diabetes coupled with any of the following:*-diagnosed before age 40 -in combination with any heart or circulatory disorder (excluding high blood pressure) -requiring 40 or more units of insulin daily Yes No In the past 12 months, have you been diagnosed, treated or had surgery for any of the following:*-heart attack, heart valve disorder, heart blockage, stroke or transient ischemic attack (TIA) -lung or respiratory disorder requiring use of a nebulizer -lung or respiratory disorder and currently use tobacco -internal cancer, melanoma, lymphoma, multiple myeloma, leukemia, systemic lupus (SLE) -chronic pancreatitis, chronic hepatitis, cirrhosis Yes No In the past 12 months, have you been recommended to have any of the following:*-treatment or counseling for alcohol or drug abuse -test, surgery, treatment or further evaluation that has not been performed or are there any test results pending Yes No In the past 5 years have you been advised by a medical professional to have any test or monitoring relating to cancer that have not been completed, results have not been received, or had abnormal test results where cancer has not been ruled out or results were inconclusive?This includes, for example, PSA screenings, mammograms, colonoscopies, and genetic screenings. Yes No In the past 5 years have you experienced any of the following, for which medical advice, diagnosis or treatment has not yet been obtained:unexplained weight loss, a lump, growth, or tumor in a breast or elsewhere, or a change in a mole? Yes No In the past 5 years have you been diagnosed or treated for leukemia, Hodgkin's DIsease, lymphoma, melanoma, sarcoma, myeloma, or any internal cancer?Treatment includes surgery, radiation, or chemotherapy. Yes No In the past 6 months have you been diagnosed, treated, or received medical advice for, or taken prescribed medication for uncontrolled high blood pressure? Yes No In the past 6 months have you received medical advice or had medical tests performed where the results were other than normal or are still pending? Yes No In the past 5 years have you been advised to have any of the following:heart surgery (any form), heart-related surgery, coronary artery surgery, angioplasty, pacemaker or defibrillator, or arteriogram? Yes No In the past 5 years have you received medical advice or taken prescribed medications for any diseased (NOT including high blood pressure), disorder or abnormality of the heart or circulatory system? Yes No In the past 5 years have you received medical advice or taken prescribed medications for myocardial infarction or heart attack, stroke or transient ischemic attack (known as TIA)? Yes No AARP Number* Are you a US citizen?* Yes No Will you be a US citizen at the time of your effective date?* Yes No If answer to this question is "No" then client is not eligible for a policy.State or country of birth* Medicare Number*Medicare Claim Number Part A Effective Date*Part A Effective Date MM slash DD slash YYYY Part B Effective Date*Part B Effective Date MM slash DD slash YYYY Social Security Number*Social Security Number Height and Weight List all medical conditions in the past 2 years*Current prescriptions*List all current prescriptions, dosages, reasons, and when first prescribedCurrently residing in nursing home?* Yes No Currently on Medicaid?* Yes No Currently on Medicaid?* Yes No Currently on Medicaid?* Yes No Currently on Medi-Cal?* Yes No Medicaid Number* Medi-Cal Number* Have prescription drug coverage that will continue after enrolling?*Usually military-related, for example, Tricare or VA coverage. Yes No Name of other Rx Coverage* Currently have Medicare Advantage plan in force?* Yes No Name of Current Med Adv Carrier* Currently have Medsup plan in force?* Yes No Name of current Medsup carrier* Current Medsup plan type*Plan F, Plan G, etc. If currently have MAPD/Medsup plan, when does coverage end? MM slash DD slash YYYY Is current Medsup plan being replaced? Yes No Is current MAPD plan being replaced? Yes No Reason for replacing Medsup coverage Additional Benefits No change in benefits, but lower premiums Fewer benefits and lower premiums Reason for replacing MAPD coverage Plan has outpatient Rx drug coverage and applicant is enrolled in Part D Disenrollment from MAPD plan Please explain reason for MAPD disenrollment Does client currently have Dental Insurance?* Yes No Have other health insurance coverage in past 63 days?* Yes No Current health insurance company*Insurance carrier Type of current health insurance plan*Employer, HMO, major med, etc. When did current coverage start? MM slash DD slash YYYY When does current coverage end? MM slash DD slash YYYY Primary care physician* Primary care physician* PCP ID #Need to look up from carrier website Dental/Vision Insurance Carrier* Aetna Ameritas Blue Shield CA Ameritas Plan(s) Selected (mark all that apply)*https://www.securitylife.com/personal-plans?agnt=18324PrimeStar® Protect Network 1000PrimeStar® Protect Network 2000PrimeStar® Protect 1000PrimeStar® Protect 2000PrimeStar® Select VisionPrimeStar® Choice VisionApplicant + OneOtherAmeritas Enrollment Completed by Agent?* Yes, enrollment complete No, Brad will complete enrollment Blue Shield Dental selectionPlan Details: https://blueshieldcamedicare.com/medicare-plans-california/medicare-supplement-plans/dental-plans/ Specialty Duo dental + vision package Dental PPO 1000 Dental PPO 1500 no dental plan Dental/Vision Quoted Premium* Medsup Requested Effective Date* MM slash DD slash YYYY Cancer Insurance Requested Effective Date* MM slash DD slash YYYY Dental/Vision Insurance Requested Effective Date* MM slash DD slash YYYY Heart Attack/Stroke Insurance Requested Effective Date* MM slash DD slash YYYY Final Expense Insurance Requested Effective Date* MM slash DD slash YYYY Requested PDP Coverage Effective Date*PDP Effective Date MM slash DD slash YYYY MedAdv Requested Effective Date* MM slash DD slash YYYY Review Election Period Chart and Confirm Effective Date Works* Confirmed Will Confirm Later Medsup Payment Type*Payment OptionElectronic Funds Transfer (Other (include in Comments section)Payment Type Comment Medsup Payment Type*Payment OptionElectronic Funds Transfer (direct withdrawal)Credit CardOther (include in Comments section)Medsup Payment Type*Payment OptionClient to set up themselves (Blue Shield CA)Other (include in Comments section)Payment Type Comment PDP Payment Type*Payment OptionElectronic Funds Transfer (direct withdrawal)Deduct from Social SecurityDirect Bill in Mail / Coupon BookPDP Payment Type*Payment OptionElectronic Funds Transfer (direct withdrawal)Deduct from Social SecurityDirect Bill in Mail / Coupon BookCredit CardLet client know we'll need a voided check with the application MedAdv Payment Type*Payment OptionElectronic Funds Transfer (direct withdrawal)Deduct from Social SecurityDirect Bill in Mail / Coupon BookCancer Ins Payment Type*Direct Bill is not availablePayment OptionElectronic Funds Transfer (direct withdrawal)Heart Attack/Stroke Ins Payment Type*Direct Bill is not availablePayment OptionElectronic Funds Transfer (direct withdrawal)Final Expense Payment Type*Direct Bill is not availablePayment OptionElectronic Funds Transfer (direct withdrawal)Dental/Vision Payment Type*Direct Bill is not availablePayment OptionElectronic Funds Transfer (direct withdrawal)Dental/Vision Payment Type*Direct Bill is not availablePayment OptionElectronic Funds Transfer (direct withdrawal)Credit CardWellcare will mail EFT form to client Name of Bank* Day of Month for Bank Draft* Day of Month for Bank Draft* Day of Month for Bank Draft* Day of Month for Bank Draft* Day of Month for Bank Draft* Day of Month for Bank Draft* Day of Month for Bank Draft* 1st 15th Checking/Account Number* Routing Number* Credit Card Company*MasterCardVisaDiscoverCredit Card Number* Credit Card Expiration* Premium drafted upon approval?* Yes No - wait until effective date Have we sold them another health insurance plan in the last five years?* Yes None How Would Client Like to Provide Medsup Application Signatures?* Adobe DocuSign Email PDF Mail Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide Medsup Application Signatures?* MID Email PDF Mail MID: No client involvement required. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide Medsup Application Signatures?* Instant App - just need client oral consent Adobe DocuSign Email PDF Mail Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide Medsup Application Signatures?* Direct Enroll Adobe DocuSign Email PDF Mail Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.Client City of Birth (for Direct Enroll security question)* Aetna has changed security question, no longer Favorite Color.How Would Client Like to Provide Medsup Application Signatures?* LEAN: Security question LEAN - Remote Signature via UHC Email Adobe DocuSign Email PDF Mail LEAN: Client will receive email from UHC with DocuSign remote signature option. Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide PDP Application Signatures?* LEAN: Security question LEAN - Remote Signature via UHC Email Adobe DocuSign Email PDF Mail MID LEAN: Client will receive email from UHC with DocuSign remote signature option. Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.Choose 3 LEAN security questions Name of street grew up on Mother's maiden name Father's middle name Name of first pet Make and model of first car Yes, we need 3 security questions now ;(Answer to LEAN security questions* Please list all three answersHow Would Client Like to Provide PDP Application Signatures?* Adobe Docusign Email PDF Mail Humana Electronic App MID Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide PDP Application Signatures?* Adobe DocuSign Email PDF Mail SVS Electronic App MID Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide PDP Application Signatures?* Adobe DocuSign Email PDF Mail MID Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide MADP Application Signatures?* Adobe DocuSign Email PDF Mail MID Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide MADP Application Signatures?* Adobe DocuSign Email PDF Mail Humana Electronic App MID Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide MAPD Application Signatures?* LEAN - Remote Signature via UHC Email (Access Code is Zip Code) Adobe DocuSign Email PDF Mail MID LEAN: Client will receive email from UHC with DocuSign remote signature option. Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.How Would Client Like to Provide MAPD Application Signatures?* Adobe DocuSign Email PDF Mail Adobe Docusign: Client will receive email to review and e-sign. Email PDF: Client will be emailed the application and can print, sign, then scan or fax back to us. Mail: We will mail client the application with a self-addressed stamped envelope.Choose a 4 Digit PIN and favorite color for Instant App* Health Assessment for MAPD - du hast!*Client have any health conditions? Yes No List health conditions for Health AssessmentClient Oral Signature*Read policy name, cost, and eff date to client. "Do I have your verbal consent to submit this application on your behalf?" I consent I do not consent Additional Comments Δ
