How to Enroll: Paper Application

Use the step-by-step instructions included with the Individual Enrollment Request Form/Attestation (PDF).

Personal information

Provide the personal information requested.

Medicare insurance information

You will need your Medicare card to complete this section.

Important questions

Please answer all five questions in this section.

Select a primary care provider (PCP), clinic, or health center from our provider network

  • To find a PCP, use our online provider directory or call Member Services at 1-800-450-1166 (TTY 711), 8 a.m. – 8 p.m., Monday through Friday, from April 1 to September 30. From October 1 to March 31, 8 a.m. – 8 p.m., seven days a week.
  • Once you've selected a PCP, write the PCP's name and provider number on your enrollment form.

Your signature

Please read the information provided, then sign and date your enrollment form.

Mail the forms to:
Keystone First VIP Choice — Enrollment
P.O. Box 7137
London, KY 40742-7137

  • If you are an authorized representative, please provide the information requested.
  • Once your enrollment is accepted by the Centers for Medicare & Medicaid Services (CMS), we will send you member materials, including your Keystone First VIP Choice (HMO-SNP) member ID card.

If you need help

Do you need help filling out the enrollment form? Do you have questions about enrolling in Keystone First VIP Choice (HMO-SNP)?

Call us at 1-855-241-3648 (TTY 711),
Monday through Friday, 8 a.m. – 8 p.m., from April 1 to September 30; or seven days a week, 8 a.m. – 8 p.m., from October 1 to March 31.

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