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OMB No. 09381378 Expires:7/31/2023 EXHIBIT 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN A MEDICARE ADVANTAGE PLAN (PART C) OR MEDICARE PRESCRIPTION DRUG PLAN (PART D) Who can use this

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Who needs y002721-083ccoxhealth2021mabase enrollment form82520v1docx?

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Anyone who wishes to enroll in the CoxHealth 2021 MA Base healthcare plan, as specified by the form name y002721-083ccoxhealth2021mabase enrollment form82520v1docx, needs to fill out this form. Individuals who are looking to avail of the benefits and coverage offered by CoxHealth under their MA Base plan should complete this enrollment form to initiate the enrollment process.

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What is y002721-083ccoxhealth2021mabase enrollment form82520v1docx?

This is an enrollment form for the Cox Health 2021 MABase program.

Who is required to file y002721-083ccoxhealth2021mabase enrollment form82520v1docx?

All participants of the Cox Health 2021 MABase program are required to file this form.

How to fill out y002721-083ccoxhealth2021mabase enrollment form82520v1docx?

The form should be completed with accurate information about the participant and submitted according to the instructions provided.

What is the purpose of y002721-083ccoxhealth2021mabase enrollment form82520v1docx?

The purpose of this form is to enroll participants in the Cox Health 2021 MABase program

What information must be reported on y002721-083ccoxhealth2021mabase enrollment form82520v1docx?

Participants need to report personal and health information as required by the program.

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