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Enrollment Form

Be advised that:

  • Medicare limits the times when most beneficiaries can add, change, or drop coverage (known as election or enrollment periods). Generally, beneficiaries who receive both Medicaid and Medicare can add, change, or drop coverage only once during each of the following:
    • January 1 – March 31
    • April 1 – June 30
    • July 1 – September 30
    • October 1 – December 31: You may request to add, change, or drop coverage, but the change won’t go into effect until January 1 of the following year.
  • By filling out this information, you will be sending an actual enrollment request to Keystone First VIP Choice.
  • Once you have submitted the online enrollment form, you will be enrolled in the plan (if your enrollment is approved by Medicare).

If you need help filling out the online enrollment form, use our step-by-step online form instructions.

We will send you a notice in the mail to let you know if your enrollment to Keystone First VIP Choice is approved or denied.