Medicare Advantage Enrollment Forms

If you are electing a Medicare Advantage plan, or switching from a Medicare Supplement plan to a Medicare Advantage plan, you must also complete a 2022 year enrollment form to alert the plan and Medicare that you are changing the way you've assigned your Medicare benefits. You must use the form specific to your plan for any changes.

2022 Forms:

• Electing KAISER: Medicare Advantage Enrollment Form
• Electing HEALTH NET: Medicare Advantage Enrollment Form
• Medicare Advantage Disenrollment form