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SeniorHealth Plans (Medicare Cost Plan)

Instructions on How to Fill out Your Enrollment Form

  1. Please have the following information available so you can transfer it to the enrollment form:
    1. Your Medicare Card or a copy of your Medicare claim number
    2. The name and phone number of your Emergency Contact
    3. If you live in any type of assisted living facility, the name, address and phone number of the facility
  2. Use a pen and fill out all of the boxes.
  3. Print clearly.
  4. Don't forget to sign the last page.
  5. If you are unable to sign, have your authorized representative sign the form where indicated.
  6. 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:

SeniorHealth Plans
Contra Costa Health Plan
595 Center Avenue, Suite 100
Martinez, CA 94553

H0502_12 031c CMS Approval 3/09/2012