SeniorHealth Plans (Medicare Cost Plan)
Instructions on How to Fill out Your Enrollment Form
- Please have the following information available so you can transfer it to the enrollment form:
- Your Medicare Card or a copy of your Medicare claim number
- The name and phone number of your Emergency Contact
- If you live in any type of assisted living facility, the name, address and phone number of the facility
- Use a pen and fill out all of the boxes.
- Print clearly.
- Don't forget to sign the last page.
- If you are unable to sign, have your authorized representative sign the form where indicated.
- If you need additional information or want to discuss any of the documents in this package please call Contra Costa Health Plan's Marketing Office at 1-800-211-8040. (Our office hours are 8:00 a.m. - 8:00 p.m. 7 days a week. Please note: From February 15 through October 15, your call will be directed to a voice message system from 5:00 p.m. - 8:00 p.m. Monday through Friday and all day Saturday, Sunday, and Holidays.)
After you have completed the form, please mail it with the required documentation and a check or money order for the first month's premium to:
Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553
H0502_12 031c CMS Approval 3/09/2012