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How to Enroll - Paper Application

Use these step-by-step instructions to fill out the Individual Enrollment Request Form (PDF).

Fill out the attestation of eligibility for an enrollment period

On the form, check the boxes that apply to you along with your Attestation of Eligibility for an Enrollment Period (PDF).

Personal information

Provide the personal information requested.

Medicare insurance information

You will need your Medicare card to complete this section.

Important questions

Please answer all five questions in this section.

Select a primary care provider (PCP), clinic, or health center from our provider network

  • To find a PCP, use our online provider directory or call Member Services at 1-855-241-3648 (TTY/TDD 711), 7 days a week, 8 a.m. to 8 p.m.
  • Once you've selected a PCP, write the PCP's name and provider number on your enrollment form.

Your signature

Please read the information provided, then sign and date your enrollment form.

Mail the forms to:
Keystone First VIP Choice — Enrollment
PO Box 7137
London, KY 40742

  • If you are an authorized representative, please provide the information requested.
  • Once your enrollment is accepted by the Centers for Medicare & Medicaid Services (CMS), we will send you member materials, including your Keystone First VIP Choice (HMO SNP) member ID card.

If you need help

Do you need help filling out the enrollment form? Do you have questions about enrolling in Keystone First VIP Choice (HMO SNP)?

Call us at 1-855-241-3648 (TTY/TDD 711), 8 a.m. - 8 p.m., 7 days a week.

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