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Request for Plan Information
Request for Plan Information
Fill out the request form below to receive an enrollment kit in the mail.
*Indicates required fields.
Name*:
Address*:
City*:
   *State:     *Zip: 
Phone:
 (optional - a sales rep may call)
E-Mail:
 (optional)
Birth Date:
Please select your health plan:
Do you have Medicare?
Yes
No
Do you have Medicaid?
Yes
No
Are you currently a member of Tufts Health Plan Medicare Preferred?
Yes
No
What other medical coverage do you have besides Medicare?

Does a former employer cover you as a retiree?
Yes
No
If yes, who is your former employer?
Are you inquiring about Tufts Health Plan Medicare Preferred for someone other than yourself (example: parent)?
Yes
No
If yes, what is the person's name?
Note:
If you have coverage from an employer or union, joining Tufts Medicare Preferred may change how your current coverage works. Read the communications your employer or union sends you. If have you questions, visit your former employer’s website, or contact the office listed in their communications. Some employers may require you to mail your application to them. If you have questions about coverage from your former employer, please call Tufts Medicare Preferred at 1-888-333-0880.
 
 
H2256-2008-56R1 9-28-07 H2229-2008-44R1 9-28-07 H3057-2008-103R1 9-28-07
 
This document was last modified: 9-28-07
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