Complete the Medicare enrollment form for New Jersey residents.

All Medicare enrollment information is confidential and should be completed by each New Jersey resident with Medicare or their authorized representative. All information is kept private and secure with encrypted web transmission.

First Name*

Middle Initial

Last Name*

Social Security Number*

Phone Number*

Address*

Apartment / Unit*

State

ZIP Code*

Sex*

Marital status*

Date of Birth*

Monthly Income

Please initial in the box below:*

Medicare Advantage Plans (Part C) and Cost Plans

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Beneficiary or Authorized Representative Signature*

Signature Date

If you are the authorized representative, please sign above and print below:

Representative's Name:

Your Relationship to the Beneficiary:

(*) Medicare Advantage Plans (Part C) and Cost Plans

Medicare Health Maintenance Organization (HMO):

A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan's network (except in emergencies).

Medicare Preferred Provider Organization (PPO) Plan:

A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Private Fee-For-Service (PFFS) Plan:

A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan's payment, terms and conditions and agrees to treat you not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers.

Medicare Point of Service (POS) Plan:

A type of Medicare Advantage Plan available in a local or regional area which combines the best feature of an HMO with an out-of-network benefit. Like the HMO, members are required to designate an in-network physician to be the primary health care provider. You can use doctors, hospitals, and providers outside of the network for an additional cost.

Medicare Special Needs Plan (SNP):

A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.

Medicare Medical Savings Account (MSA) Plan:

MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.

Medicare Cost Plan:

In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan's network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Medicare Medicaid Plan (MMP):

An MMP is a private health plan designed to provide integrated and coordinated Medicare and Medicaid benefits for dual eligible Medicare beneficiaries.