It’s easy to enroll by mail.

1. Download an application form by clicking on the appropriate link below.
2. Complete the form.
3. Print it out.
4. Mail it to us at the address shown on the form.

Your monthly plan premiums vary by plan and choice of drug coverage. The monthly premium is listed on the enrollment form.

The following forms require Adobe Reader. You can click here to download the latest version of Adobe Reader for free.

Alliance Medicare Rx

Alliance Medicare Rx enrollment form

• Serves people with Medicare who reside in the state of Michigan.
• Choose between Basic, Value or Enhanced drug coverage.

Alliance Medicare PPO

Alliance Medicare PPO enrollment form

• Serves people with Medicare who reside in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair, and Washtenaw counties.
• Choose between Basic or Enhanced drug coverage, or no drug coverage at all.
• Choose optional dental coverage with Plan 1 or Plan 2, for an additional premium.

Alliance Medicare PPO Value Plan enrollment form

• Has a lower premium than Alliance Medicare PPO, and an upfront deductible of $500
• Serves people with Medicare who reside in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair, and Washtenaw counties.
• Choose between Basic or Enhanced drug coverage, or no drug coverage at all.
• Choose optional dental coverage with Plan 1 or Plan 2, for an additional premium.

HAP Senior Plus

HAP Senior Plus – Henry Ford Health System Network enrollment form

• Serves people with Medicare who reside in Wayne, Oakland, and Macomb counties.
• Choose between Basic or Enhanced drug coverage, or no drug coverage at all.
• Choose optional dental coverage with Plan 1 or Plan 2, for an additional premium.

HAP Senior Plus – Expanded Network enrollment form

• Serves people with Medicare who reside in Wayne, Oakland, Macomb, Genesee, Lapeer, Livingston, Monroe, St. Clair, and Washtenaw counties.
• Choose between Basic or Enhanced drug coverage, or no drug coverage at all.
• Choose optional dental coverage with Plan 1 or Plan 2, for an additional premium.