Submit this completed form via mail to the address provided in the guidelines or fax it to the listed fax number for swift processing. Ensure to include your contact information for any follow-ups. For any online submissions, follow the outlined directions carefully. It's advisable to keep a copy of your form for your records.

For the 2024 enrollment period, the Important dates include: Open Enrollment Period from October 15 to December 7, 2023, and Annual Election Period from April 1 to June 30, 2024. Health plan changes can take effect starting January 1, 2024.

The purpose of this form is to facilitate the enrollment of eligible individuals into the AARP Medicare Advantage plan for the year 2024. It collects essential personal information and demographic data to ensure proper processing of your application. Additionally, the form allows UnitedHealthcare to manage health care needs efficiently and provides necessary support to users.

• 1. Last Name: The applicant's last name.
• 2. First Name: The applicant's first name.
• 3. Birthdate: The applicant's date of birth.
• 4. Sex: The applicant's gender.
• 5. Home Phone Number: The applicant's primary home phone number.
• 6. Mobile Phone Number: The applicant's mobile phone number.
• 7. Medicare Number: The applicant's Medicare identification number.
• 8. Permanent Residence Address: The primary residence of the applicant.
• 9. City: City of residence.
• 10. County: County of residence.
• 11. State: State of residence.
• 12. ZIP Code: Postal ZIP code.
• 13. Mailing Address: Optional mailing address if different from the permanent address.
• 14. Email Address: An optional field for the applicant's email.
• 15. Other Insurance Details: Information about any additional insurance plans.
• 16. Payment Options: Selected method for premium payments.
• 17. Agent Name/ID Number: Information regarding the agent assisting with the enrollment.

If you fail to submit this form, you may miss the opportunity for enrollment in a Medicare Advantage plan. It's crucial to ensure the form is accurately completed and submitted on time to avoid service disruptions. Unsubmitted applications may lead to delays in coverage, necessitating further steps for enrollment.

• Missed Enrollment Deadlines: Not submitting can lead to missed deadlines, affecting plan selection.
• Service Delays: Failure to submit may delay the initiation of health care services.
• Inaccurate Information: Incomplete forms can lead to processing errors and delays.

• 1. Initial Enrollment: First-time application for Medicare Advantage plans.
• 2. Plan Changes: Switching from one Medicare plan to another during open enrollment.
• 3. Coverage Renewals: Updating existing enrollment to continue coverage.
• 4. New Eligibility: Applying upon eligibility for Medicare or due to life changes.
• 5. Clarifications on Coverage: For queries related to new Medicare plans available.