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OMB No. 09381378 Expires:7/31/2023INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN A MEDICARE ADVANTAGE PLAN (PART C) Who can use this form? People with Medicare who want to join a Medicare Advantage

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5. Read the instructions provided on the form carefully.
6. Fill out the required fields on the form accurately.
7. If applicable, provide any supporting documentation or attachments as mentioned in the instructions.
8. Double-check all the filled information for accuracy.
9. Once completed, review the form again and make sure you haven't missed anything.
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