Please follow the instructions and complete the Enrollment Form, today. We encourage you to read the
Summary of Benefits before completing an Individual Enrollment Request form.
2019 Online Enrollment Form - Coming Soon
2018 Online Enrollment Form
2019 Molina Medicare Enrollment Instructions - Coming Soon
2019 Molina Medicare Enrollment Form - Coming Soon
2018 Molina Medicare Enrollment Instructions
2018 Molina Medicare Enrollment Form
Following Steps 1 – 6 of the Enrollment Instructions PDF above will assist you with the enrollment process.
If you need help completing this enrollment form or have questions about plan benefits prior to enrollment, please call us toll-free at (866) 403-8293, TTY/TDD 711, 7 days a week, 8:00 a.m. – 8:00 p.m. local time. Molina Medicare determines when your Enrollment Form is considered to be complete based on Medicare enrollment guidelines. The Enrollment is subject to approval from the Centers for Medicare & Medicaid Services (CMS). If your enrollment is not accepted by CMS, we will notify you immediately.
CMS Medicare Online Enrollment Center
Medicare beneficiaries may also enroll in the Molina Medicare Options Plus plan through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
*Printed copies of information posted on our website are available upon request.
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