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Simple AF APP
SIMPLE AF APP
For quick submission of MAPD or PDP enrollments
First name
MI
Last name
Date of Birth
MM slash DD slash YYYY
Email
Phone
Medicare number
Part A effective date
MM slash DD slash YYYY
Part B effective date
MM slash DD slash YYYY
Residence Address 1
Residence Address 2
City
State
Zip
County
Different mailing address
Mailing address is different
Mailing Address 1
Mailing Address 2
City
State
Zip
Plan requested:
Premium
Primary Care Physician (MAPD only)
Requested effective date
MM slash DD slash YYYY
Payment method
Social Security deduction
Railroad Retirement Deduction
Direct Bill
Do I have your consent to enroll you in [PLAN], effective [DATE], with a premium of [PREMIUM]?
(Required)
Yes
SIMPLE AF APP
For quick submission of MAPD or PDP enrollments
First name
MI
Last name
Date of Birth
MM slash DD slash YYYY
Email
Phone
Medicare number
Part A effective date
MM slash DD slash YYYY
Part B effective date
MM slash DD slash YYYY
Residence Address 1
Residence Address 2
City
State
Zip
County
Different mailing address
Mailing address is different
Mailing Address 1
Mailing Address 2
City
State
Zip
Plan requested:
Premium
Primary Care Physician (MAPD only)
Requested effective date
MM slash DD slash YYYY
Payment method
Social Security deduction
Railroad Retirement Deduction
Direct Bill
Do I have your consent to enroll you in [PLAN], effective [DATE], with a premium of [PREMIUM]?
(Required)
Yes
See my screen