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Disclaimer -

This is a solicitation for insurance and an agent may contact you.

By submitting my information via this form, I consent to having Molina Healthcare collect my personal information. I understand and agree that my information will be used and shared in accordance with Molina Healthcare's Privacy Policy and Terms of Use.

Enroll today!

When you join Molina Medicare, you can be sure your individual needs are met.

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.

Enroll online

icon PDF 2024 Online Enrollment Form

Enroll by mail

icon PDF 2024 Enrollment Form

Mail to:
Molina Healthcare, Inc.
Attn: Enrollment Accounting
P.O. Box 22800
Long Beach, CA 90801-9945

 

If you need help completing this enrollment form or prior to enrollment have questions about plan benefits, please call us Toll Free: (866) 403-8293, TTY/TDD: 711, Monday to Saturday, 8:00 a.m. to 8:00 p.m. local time. Molina Medicare determines when your Enrollment Form is complete based on Medicare enrollment guidelines. The Enrollment Form is subject to approval from 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 plans 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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