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 premium is based on the option you choose. 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 Option 1 and Option 2.

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 Option 1 or Option 2.
• Choose optional dental coverage with Plan 1 or Plan 2, for an additional premium.

HAP Senior Plus

HAP Senior Plus – Henry Ford enrollment form

• Serves people with Medicare who reside in Wayne, Oakland, and Macomb counties.
• Choose between Option 1, Option 2 or Option 3.
• 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 Option 1, Option 2 or Option 3.
• Choose optional dental coverage with Plan 1 or Plan 2, for an additional premium.