Age-In Selection Form
Please return this form with a copy of your Medicare card.
Member Information
Primary Retiree Name:
Primary Retiree SSN: - - Gender: Male Female
Date of Birth: / / Phone: ( )
Address:
Dependent Information
Name of Dependent:
SSN of Dependent: - - Gender: Male Female
Date of Birth: / /
Please enroll me into one:
Medicare Indemnity Plan (BCBS)
*Split plan option for
dependent(s) under 65:
Medicare HMO Plan (BCBS)
Aetna Medicare Advantage Plan*
BCBS HMO
BCBS Indemnity (PPO)
Enhanced Medicare Advantage Plan*
This request must be signed by the member, unless there is an appointed Durable Power of Attorney, which
a copy must be attached.
Signature: Date:
Medicare Eligibility
Retiree: Medicare Part A YES NO Medicare Part B YES NO
Effective Date: Effective Date:
Medicare ID (HCN) #:
Dependent: Medicare Part A YES NO Medicare Part B YES NO
Effective Date: Effective Date:
Medicare ID (HCN) #:
If you miss this deadline, you will have another opportunity to change coverage during the open enrollment period
later in October.
P
lease return the completed form with a copy of your Medicare card to:
Fulton County Pension Office
ATTN: Retiree Benefits
141 Pryor Street, Suite 7001
Atlanta, GA 30303
(404) 612-7606
(404) 612-1312 (E-FAX)
OR
Email: pensionunit@fultoncountyga.gov
Office Use Only
Submitted Effective Date:
click to sign
signature
click to edit
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