By signing below, you confirm that you are authorized by state law to act on their behalf. You may be asked to provide documentation showing your authority.

Terms and conditions I understand that by submitting this form, I am requesting enrollment in the Medicare Prescription Payment Plan. Select Health will send me a notice confirming when my enrollment is active. Until I receive that notice, I am not enrolled in the program. I understand that I may opt out at any time after enrollment.

I understand that by submitting this form, I am requesting enrollment in the Medicare Prescription Payment Plan. Select Health will send me a notice confirming when my enrollment is active. Until I receive that notice, I am not enrolled in the program. I understand that I may opt out at any time after enrollment.