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OMB No. 09381378 Expires: 6/30/2026Exhibit 1: MODEL INDIVIDUAL ENROLLMENT REQUEST FORM TO ENROLL IN A MEDICARE PRESCRIPTION DRUG PLAN (PART D)Who can use this form? People with Medicare who want to
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How to fill out model individual enrollment request
How to fill out model individual enrollment request
01
Obtain a copy of the model individual enrollment request form
02
Fill out personal information accurately, including name, date of birth, address, and contact information
03
Provide information about any existing insurance coverage
04
Indicate the desired coverage start date
05
Sign and date the form where required
06
Submit the completed form to the appropriate insurance provider
Who needs model individual enrollment request?
01
Individuals who are seeking to enroll in a new insurance plan
02
Individuals who are looking to make changes to their existing insurance coverage
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What is model individual enrollment request?
Model individual enrollment request is a form used to request enrollment in an individual plan.
Who is required to file model individual enrollment request?
Individuals who wish to enroll in a specific plan must file a model individual enrollment request.
How to fill out model individual enrollment request?
To fill out a model individual enrollment request, you must provide personal information and select the desired plan.
What is the purpose of model individual enrollment request?
The purpose of model individual enrollment request is to formally request enrollment in a specific individual plan.
What information must be reported on model individual enrollment request?
The information required on a model individual enrollment request includes personal details, plan selection, and any supporting documentation.
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