HMO Enrollment Form

Enrollment Form Addendum

Electronic Funds Transfer (EFT) Form

Optional Supplemental Benefits Enrollment Form

In order to enroll in PrimeTime Health Plan through CMS Medicare Online Enrollment Center, you will need to have JavaScript enabled in your internet browser. Please enable JavaScript and then refresh this page.

Medicare beneficiaries may enroll in PrimeTime Health Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. You may also enter your zip code in the box below and then click the "Go" button. This action will automatically redirect you to the CMS Medicare Online Enrollment Center’s website.