Enrollment Request Form to Enroll in a Medicare Advantage Plan (Parts C) with Medicare Prescription Drug Plan (Part D)

Questions or Need Assistance? Call 1-888-477-4663 (TTY: 711)

MA HMO Enrollment Application – In Person
  • Enrollment Information
  • Enrollment Section 1
  • Enrollment Section 2
  • Enrollment Section 2 continued
  • Additional Information
  • Agent Checklist
  • Summary

Enrollment Request Form

Who can use this form?
People with Medicare and Medicaid who want to join a Medicare Advantage Plan

To join a plan, you must:

  • Be a United States citizen or be lawfully present in the U.S.
  • Live in the plan’s service area

Important: To join a Medicare Advantage Plan, you must also have both:

  • Medicare Part A (Hospital Insurance)
  • Medicare Part B (Medical Insurance)

When do I use this form?
You can join a plan:

  • Between October 15 – December 7 each year (for coverage starting January 1)
  • Within 3 months of first getting Medicare
  • In certain situations where you’re allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

  • Your Medicare Number (the number on your red, white, and blue Medicare card)
  • Your permanent address and phone number

Note: You must complete all items in Section 1. The items in Section 2 are optional — you can’t be denied coverage because you don’t fill them out.


  • If you want to join a plan during fall open enrollment (October 15 – December 7), the plan must get your completed form by December 7.
  • Your plan will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?
Complete and submit the online enrollment form starting on the next page
or download the enrollment application (pdf) and send your completed and signed form to:
 Nascentia Health Plus
 1050 West Genesee Street
 Syracuse, NY 13204

Once they process your request to join, they’ll contact you.

How do I get help with this form?
Call Nascentia Health Plus at 1-888-477-4663 (TTY: 711).

Or call Medicare at 1-800-MEDICARE (800-633-4227). TTY users can call 1-877-486-2048.

En español: Llame a Nascentia Health Plus al 888-477-4663-/TTY 7 o a Medicare gratis al 800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.

Last Updated on August 31, 2021