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 except Medicare Advantage HMO plans. To assure continued care with us, you will need to select one of the following Medicare Advantage HMO plans during Open Enrollment 2019:

AARP United Health
Blue Shield 65+
Humana Gold Plus
SCAN
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Are you planning on changing your Medicare insurance during this open enrollment season?* This field is requiredPlease select the box that applies to you:
I will be switching to an AARP United Health Medicare Advantage HMO Plan
I will be switching to a Blue Shield 65+ Medicare Advantage HMO Plan
I will be switching to a Humana Gold Plus Medicare Advantage HMO Plan
I will be switching to a SCAN Medicare Advantage HMO Plan
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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