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Enroll a Member

Keystone First VIP Choice strives to make the member enrollment process as easy as possible. As a reminder, you're required to provide a  pre-enrollment checklist (PDF), summary of benefits (PDF), multi-language insert (PDF), and non-discrimination notice (PDF) any time you provide an enrollment request to a beneficiary.

Enrollment application

When filling out the enrollment application, make sure that the correct information is in the following sections:

  • NIPR number.
  • Agent broker ID — Use your insurance license number.
  • Agent writing number — Use your Rep ID number.

Use the individual enrollment request form and fax cover sheet, found below, to send your enrollment applications, along with the scope of appointment confirmation form. Fax each application 1 at a time to 1-855-822-9400.

Keystone First VIP Choice enrollment forms

Y0093_WEB_318377