Enroll Now

EMI HEALTH MEDICARE PRESCRIPTION DRUG PLAN INDIVIDUAL ENROLLMENT FORM

To enroll please provide the following information:

Please correct the following error(s)

Plans



Enrollee Information



Permanent Address

Mailing Address

Emergency Contact Information

Please Provide Your Medicare Insurance Information

Please take out your Medicare Card to complete this section.

  • Please fill in these blanks so they match your red, white and blue Medicare card OR
  • Attach a copy of your Medicare card or your letter from the Social Security Administration or Railroad Retirement Board.
  • You must have Medicare Part A or Part B (or both) to join a Medicare Prescription drug plan.
Medicare Card

Please select a premium payment option:

You can pay your monthly plan premium by mail. Electric Funds Transfer(EFT), each month. You can also choose to pay your premium by automatic deduction from your Social Security Check each month.

If you qualify for extra help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. If Medicare only pays a portion of this premium, we will bill you for the amount that Medicare does not cover.




Please answer the following questions to help Medicare coordinate your benefits

Some individuals may have other drug coverage, including other private insurance, TRICARE, Federal employee health benefits coverage, VA benefits, or State pharmaceutical assistance programs.


Long Term Facility Resident


If you are the authorized representative, you must provide the following information:



EMI Health is a Medicare Contractor for Utah and Idaho.

Medicare beneficiaries may also enroll in EMI Health through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.