Enroll for 2022

Agents are standing by. Contact Trout Insurance for a complete review of Your Medicare Options. Call 828.279.4681

• Are you eligible for enrollment in 2022? We can review guidelines for enrollment with you. Click Here.

• The Annual Enrollment Period (AEP) begins October 15, 2021 for members already enrolled in Medicare. Please contact us for exceptions.

Turning 65- New to Medicare

• You may enroll in a Medicare plan three months before the month you turn 65, the month of your birthday, and 3 months after.

• All plans including Medicare Supplements are guarantee issue during this enrollment period (IEP).

We represent Medicare Advantage HMO, PPO and PFFs organizations with a Medicare contract. Enrollment in any plan depends on contract renewal. You must continue to pay your Medicare Part B premium.

Please complete this form so we may get started to review your Medicare medical and Rx Prescription plan options for 2022.

2022 Medicare Enrollment Form for Over 65

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Date of Birth *

My Current Agent Is: *

Zip Code *

County *

Other Agent *

Medicare Part B eligibility date (on your Medicare Card) *

My Current Plan *

My Current Insurance Company *

Primary Care Doctor *

Specialist 1 *

Specialist 2 *

Your Preferred Local Pharmacy *

Prescriptions Taken Regularly:

Rx 1 Name *

Rx 1 Dosage *

Rx 1 How Often *

Rx 2 Name *

Rx 2 Dosage *

Rx 2 How Often *

Rx 3 Name *

Rx 3 Dosage *

Rx 3 How Often *

Rx 4 Name *

Rx 4 Dosage *

Rx 4 How Often *

Rx 5 Name *

Rx 5 Dosage *

Rx 5 How Often *

Rx 6 Name *

Rx 6 Dosage *

Rx 6 How Often *

Questions/ Comments/ Notes *

Submit

Enroll For 2022

2022 Medicare Enrollment Form for Over 65

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