Blue MedicareRx Paper Enrollment

You can either print the paper enrollment form and fill it out by hand, or open the form on your computer and type the information into the form.

Download, print, then complete the form by hand:

  1. Go to the enrollment forms area of the documents section get the form and print it out.
  2. Print your information legibly in each section.
  3. Sign and date the form on page 6.
  4. Keep a copy for your records.
  5. If anyone helps you complete your application, that individual must sign the enrollment form and indicate his or her relationship to you.
  6. Send the original form with your signature to the address listed on the front of the form.

Fill out the form on your computer using your keyboard and mouse:

  1. Go to the enrollment forms area of the documents section and open the form in your browser (or save to your computer and then open it).
  2. Use your mouse or tab key to move from one part of the form to the next. Click on a box to check it. Use the tab key to move from one fill-in area to the next, such as from the name fields to Birth Date on the enrollment form or Member Number on the change form.
  3. Type your information in each shaded box (click “Highlight Fields” at the top of the form to see the shaded areas you need to complete).
  4. Once you’ve entered all of your information, print the form.
  5. Sign and date the form on page 6.
  6. If anyone helps you complete your application, that individual must sign the enrollment form and indicate his or her relationship to you.
  7. Keep a copy for your records.
  8. Send the original form with your signature to the address listed on the front of the form.

Direct link to the Spanish enrollment form(s):