Are you a current member?

Welcome to PacificSource Medicare Enrollment

When you can enroll:

• When you become eligible for Medicare
• The Annual Enrollment Period: (October 15 – December 7)
• The Open Enrollment Period: (January 1 – March 31) If you are already enrolled in a Medicare Advantage plan
• Special Enrollment Periods: There are many other circumstances for which you could be eligible to enroll, outside these three periods.
• Dual special needs plans (D-SNP) have additional enrollment periods. Call us for details.

To enroll in one of our plans, please print the form below and mail or fax it to us. Our address and fax number are on the form. If you would like to enroll by phone or receive enrollment forms by mail, please call us at 855-265-5969, TTY: 711. We accept all relay calls.

By submitting an enrollment application, you are requesting enrollment with PacificSource Medicare. We then send your application to the Centers for Medicare & Medicaid Services (CMS) for approval. If CMS approves your application, you will be enrolled in the plan you selected. You will receive a confirmation notice and plan benefit information in the mail. If CMS denies your enrollment request, you will receive a notice in the mail telling you why your request was denied.