Please complete and return this form to Medicare Broker Services: to by to (800) 309-5095 or by (844) 202-6811 E-mail fax calling There is an enrollment kit limit of 50 per kit type, per day. Please note that orders cannot be shipped to P.O. Boxes. Please allow 7 days for orders to ship. You can expect to receive 30 kits per box (Will not exceed 25 lbs per box). BROKER SHIPPING INFORMATION Name: BROKER ID/NPN: Address City State Zip Code: Phone E-mail address Send confirmation e-mail to: Same as listed above Other: Residential Business Special instructions: (Continue) QTY. FORMS/BULK MATERIALS (Limit 50) FORMS/BULK MATERIALS (Limit 50) QTY. Kit County Crosswalk Counties PLAN SELECTION Allwell Medicare (HMO) Bexar, Guadalupe, Wilson H0062-001 Collin, Dallas, Denton, Rockwall, Smith, Tarrant H0062-002 Hidalgo, Cameron H0062-003
Please complete and return this form to Medicare Broker Services: E-mail to by fax to (800) 309-5095 or by calling (844) 202-6811 There is an enrollment kit limit of 50 per kit type, per day. Please note that orders cannot be shipped to P.O. Boxes. Please allow 7 days for orders to ship. You can expect to receive 30 kits per box (Will not exceed 25 lbs per box). BROKER SHIPPING INFORMATION Name: BROKER ID/NPN: Address City State Zip Code: Phone E-mail address Send confirmation e-mail to: Same as listed above Other: Residential Business Special instructions: (Continue) FORMS/BULK MATERIALS (Limit 50) QTY. FORMS/BULK MATERIALS (Limit 50) QTY. Kit County Crosswalk PLAN SELECTION Counties Allwell Medicare (HMO) H0062-001 Bexar, Guadalupe, Wilson H0062-002 Collin, Dallas, Denton, Rockwall, Smith, Tarrant H0062-003 Hidalgo, Cameron