👤

Step 1 — Beneficiary Information

Enter the Medicare beneficiary's personal details.

First Name *

Middle Initial

Last Name *

Medicare Number *

Date of Birth *

Gender *

Part A Effective Date

Part B Effective Date

Requested Effective Date

📍

Step 2 — Contact Information

Your address helps us find local plans. We'll contact you with options.

Street Address *

Apt/Suite

City *

State *

ZIP Code *

Phone Number *

Email Address

🩺

Step 3 — Primary Care Physician (PCP)

Tell us about your preferred primary care doctor.

PCP First Name

PCP Last Name

PCP ID (Optional)

Are you a current patient?

📋

Step 4 — Plan & Enrollment Details

Select your enrollment period and plan information.

📞Agent fills this section. Mercy will complete the plan details during your consultation call at no obligation.

Enrollment Period

Will Work After Enrollment?

Employer Coverage Acknowledged?

Other Prescription Coverage?

Other Medical Coverage?

Contract

PBP

Segment

Premium

📝

Step 5 — Special Enrollment (SEP)

Complete this section only if you have a Special Enrollment Period.

🔖 SEP Codes — Select all that apply

LEC Start Date

LEC End Date

Other Reason (If OTH selected)

🌐

Step 6 — Language & Preferences

Select your preferred language and communication options.

🗣️ Preferences — Select all that apply

EnglishSpanishLarge PrintHRA Completed

🔐

Step 7 — Confirmation (Office Use)

Filled in by Mercy's team upon successful enrollment.

ℹ️This section is completed by the agent after your enrollment is processed.

Date Enrolled

Confirmation Number

Date Emailed

👤

Step 1 — Beneficiary Information

Enter the Medicare beneficiary's personal details.

First Name *

Middle Initial

Last Name *

Medicare Number *

Date of Birth *

Gender *

Part A Effective Date

Part B Effective Date

Requested Effective Date

📍

Step 2 — Contact Information

Your address helps us find local plans. We'll contact you with options.

Street Address *

Apt/Suite

City *

State *

ZIP Code *

Phone Number *

Email Address

🩺

Step 3 — Primary Care Physician (PCP)

Tell us about your preferred primary care doctor.

PCP First Name

PCP Last Name

PCP ID (Optional)

Are you a current patient?

📋

Step 4 — Plan & Enrollment Details

Select your enrollment period and plan information.

📞Agent fills this section. Mercy will complete the plan details during your consultation call at no obligation.

Enrollment Period

Will Work After Enrollment?

Employer Coverage Acknowledged?

Other Prescription Coverage?

Other Medical Coverage?

Contract

PBP

Segment

Premium

📝

Step 5 — Special Enrollment (SEP)

Complete this section only if you have a Special Enrollment Period.

🔖 SEP Codes — Select all that apply

LEC Start Date

LEC End Date

Other Reason (If OTH selected)

🌐

Step 6 — Language & Preferences

Select your preferred language and communication options.

🗣️ Preferences — Select all that apply

EnglishSpanishLarge PrintHRA Completed

🔐

Step 7 — Confirmation (Office Use)

Filled in by Mercy's team upon successful enrollment.

ℹ️This section is completed by the agent after your enrollment is processed.

Date Enrolled

Confirmation Number

Date Emailed

Medicare Advantage Application

Medicare Advantage Application