Paper enrollment

You can download and print the form or open a fillable form on your computer to enter your information electronically.

Download and print method

  1. Click “Paper enrollment form”PDF icon to open, download and print
  2. Clearly print your information for each section
  3. Sign and date on page 6
  4. If anyone helps you complete the form, make sure that person signs it and indicates the relationship type on page 6
  5. Make a copy of the form for your records, if desired
  6. Send the original with your signature to the address listed on the front of the form

Fillable form method

  1. Click “Paper enrollment form”PDF icon to open
  2. Save it to your computer using “Save as” and give it a new name (you will not be able to save it to JourneyRxMedicare.com)
  3. Type your information in each section
  4. Once you’ve entered your information, print the form
  5. Sign and date on page 6
  6. If anyone helps you complete the form, make sure that person signs the form and indicates the relationship type on page 6
  7. Keep a copy for your records, if desired
  8. Send the original with your signature to the address listed on the front of the form

If you have questions or need assistance, contact our Medicare Solutions specialists.