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Customer ID# Customer ID# A Blue Cross Medicare Advantage Plan from Keystone Health Plan East Individual Enrollment NON-Group Election Form Please contact Keystone 65 HMO if you need information in
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98 Medical + Dental (004) 61.10 Total Premium (042) 122.30 Total Premium (008) 118.90 Total Amount Spent (004) 63.50 Total Amount Spent (006) 77.20 Total Amount Spent (002) 71.80 Medical Only (No Rx) (021) 92.40 Medical Only (No Rx) (002) 68.50 Total Annual Fee (042) 13.10 Annual Fee (008) 10.60 Total Annual Fee (002) 9.30 Annual Fee Spent (001) 86.40 Additional Costs of Care (004) 9.30 Additional Costs of Care (006) 9.10 Additional Costs of Care (002) 2.40 Additional Costs of Care (021) 0.10 Additional Costs of Care (002) 7.30 Total Additional Costs of Care (001) 3.10 Additional Costs of Care (021) 0.40 Additional Costs of Care (002) 5.90 Additional Expense for Care (051) 18.30 Additional Expense for Care (051) 18.40 Additional Expense for Care (011) 13.60 Covered Services/Benefits (034) 0.60 Covered Services/Benefits (051) 11.80 Covered Services/Benefits (011) 13.60 Other Information Needed (034) 0.60 Other Information Needed (051) 11.80 Other Information Needed (011) 13.60 Additional Information Needed (001) 2.80 Additional Information Needed (021) 0.30 Additional Information Needed (002) 7.30 Additional Information Needed (021) 0.60 Patient Eligibility Information No Patient Identification Number was provided. The address associated with this account is an out-of-service address. The address associated with the account is a P.O. Box address. The contact information given in the enrollment statement has expired. The information provided by Keystone 65 HMO may be different that what you receive from your carrier. In the event that it is, please contact them directly. Please provide the following: First and Last Name. E-mail Address Account Number Please indicate whether you have a preferred or common carrier.

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Customer ID is a unique identifier assigned to each customer in a system.
All customers are required to have a customer ID.
Customer ID is usually assigned by the system admin or automatically generated by the system.
The purpose of customer ID is to uniquely identify each customer and track their activities and transactions.
Customer ID does not typically require additional information to be reported. It is used as an identifier.
There is no specific deadline to file customer ID as it is generated or assigned upon the creation of a customer account.
There is no penalty for late filing of customer ID as it is not a filing requirement but an identifier.
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