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Enroll in a plan AARP MedicareComplete Review your application Statement of Understanding Submit your application
Please review the following information for accuracy. Please note that once you submit your application, you will no longer be able to make edits online. To make changes to any of the information you entered, please find the appropriate section in the menu bar above and click on the link. You will then be taken to that part of the application and will be able to make changes. The enrollment process will not be complete until your submitted application has been reviewed and approved.
Medicare Eligibility: EDIT Beneficiary Information Last Name
wade
First Name
edith
Middle Initial
r
Claim Number
558986486a
Gender
F
Entitlements and Effective Dates Hospital (Part A) 03/01/2009 Medical (Part B) 03/01/2009
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Additional Information SSN
558986486 (optional)
Birth Date
11/15/1956
Marital Status
S
ESRD
No
Your Contact Information: EDIT Permanent Residence Street Address
3721 ashley ln
Apt/Ste City
ft worth
State
TX
ZIP Code
76123
Additional Contact Information Primary Telephone
(817)937-7057
Email Address
loveunlimd@aol.com (optional)
Language Pref. English
Emergency Contact Information Contact Name
edith wade
Telephone Number
(817)937-7057
Relationship to You
self
Medicaid & Institutions: EDIT Medicaid Currently Enrolled
No
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Institutions Reside in Facility
No
Other Coverage: EDIT Employment Status Self/Spouse Currently Employed
No
Health Insurance Coverage Other Coverage Yes Insurance Carrier
texs true choice
Group Number
pdx9520
ID Number
pdx952000221893
Street Address
po mbx 12170
City
overland pk
State
KS
ZIP Code
66282
Prescription Drug Coverage Drug Coverage
Yes
Employer/Union Yes Name of Prescription Plan
texas true choice
Group Number
PDX9520
ID Number
pdx95200221893
Additional Plan Options: EDIT Primary Care Physician PCP Name
Caroline Woodland
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PCP Number Current Patient
Yes
Dentist Dentist Name
Premium Plan Options Deduct Premium Yes
Relationship to Enrollee: EDIT I am the Medicare beneficiary listed on this enrollment application, or I am helping the Medicare beneficiary complete this enrollment application.
Print this page for your records.
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