Medicare Insurance Change Form

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Name* This field is required.
First Name
Middle Name
Last Name
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Date of Birth* This field is required.
MM/DD/YYYY
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E-mail Address* This field is required.
example@example.com
Confirm Email
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We understand that our recent Medicare changes are difficult. We would like to provide our patients with as much time and resources as possible to help you make the best choice for your healthcare needs.

What changes do you plan on making during this year's open enrollment, and how can we help make your transition (if any) easier? Please check the box in the next question that best applies to you. Thank you for your cooperation and understanding.
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Effective January 1, 2020:

Edinger Medical Group will only accept Medicare Advantage HMO plans. To assure continued care with EMG, you will need to select one of the following Medicare Advantage HMO plans during Open Enrollment 2019:

AARP United Healthcare
Aetna Senior HMO
Blue Shield Inspire
Humana Gold Plus
SCAN
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Are you planning on changing your Medicare insurance during this open enrollment season?* This field is required.Please select the box that applies to you:
I selected the AARP United Health Medicare Advantage HMO Plan to stay with Edinger Medical Group.
I selected the Aetna Senior HMO Plan to stay with Edinger Medical Group.
I selected the Blue Shield Inspire Medicare Advantage HMO Plan to stay with Edinger Medical Group.
I selected the Humana Gold Plus Medicare Advantage HMO Plan to stay with Edinger Medical Group.
I selected the SCAN Medicare Advantage HMO Plan to stay with Edinger Medical Group.
I will not be changing my Medicare insurance this open enrollment season. I would like my medical records mailed to me.
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If you still have questions or concerns regarding the recent Medicare changes, please give us a call at 714-965-2536.
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