It’s easy to enroll online. Please print these instructions to guide you through the online enrollment process:

1. Open the desired enrollment form by clicking on the appropriate link below. The forms require Adobe Reader version 7.0 or later for online submission.
2. Review the disclaimers and click Accept to continue.
3. Complete the form by typing directly on the form. To start over, click on the Clear button on the last page of the form.
4. Print a copy of the completed form for your records by clicking on the Print button on the last page of the form. NOTE: Once submitted you will not be able to print the form.
5. Submit your application by clicking on the Submit button on the last page of the form.
6. Upon submitting the form, you will be redirected to a confirmation page confirming that you have completed the online enrollment process.
7. Print a copy of the confirmation for your records.

Alliance Medicare Rx

Alliance Medicare Rx enrollment form
(Requires Adobe Reader version 7.0 or later)

• 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
(Requires Adobe Reader version 7.0 or later)

• 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
(Requires Adobe Reader version 7.0 or later)

• 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
(Requires Adobe Reader version 7.0 or later)

• 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
(Requires Adobe Reader version 7.0 or later)

• 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.