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OMB No. 09381378 Expires: 7/31/20232023 Medicare Advantage Plan Individual Enrollment Request Form Cover Page Who can use this form? People with Medicare who want to join a Medicare Advantage Plant

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How to fill out enrollment-form-texas-houston-souformast-hmo-dsnp

01

Obtain the enrollment form specific to the Texas Houston SouformaST HMO DSNP plan.

02

Fill out all required personal information such as name, address, date of birth, and contact information.

03

Provide details of your current health insurance coverage, if applicable.

04

Review the form to ensure all information is accurate and complete.

05

Sign and date the form as required.

06

Submit the completed enrollment form either online, by mail, or in person as instructed by the plan.

Who needs enrollment-form-texas-houston-souformast-hmo-dsnp?

01

Individuals who are eligible for the Texas Houston SouformaST HMO DSNP plan and wish to enroll in this healthcare coverage.

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What is enrollment-form-texas-houston-souformast-hmo-dsnp?

This form is used to enroll in a specific HMO D-SNP plan in Houston, Texas.

Who is required to file enrollment-form-texas-houston-souformast-hmo-dsnp?

Individuals who are eligible for the HMO D-SNP plan in Houston, Texas.

How to fill out enrollment-form-texas-houston-souformast-hmo-dsnp?

The form can be filled out online or by contacting the plan directly for assistance.

What is the purpose of enrollment-form-texas-houston-souformast-hmo-dsnp?

The purpose is to enroll in a specific HMO D-SNP plan in Houston, Texas for healthcare coverage.

What information must be reported on enrollment-form-texas-houston-souformast-hmo-dsnp?

Personal information, contact details, medical history, and eligibility for the plan.

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