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Summary

You and/or your insured dependents must be enrolled for both portions of Medicare (Hospital Part A and Medical Part B), when first eligible. Provide this information to ETF using this form.

To complete the form electronically, be sure to first download the form, complete using Acrobat Reader, and save. Note: ETF is unable to assist with Adobe Acrobat Reader technical or compatibility issues. If you need assistance, please visit Adobe’s help site at https://helpx.adobe.com/support/reader.html.

Once you click on the "Submit your completed application securely here" link below, you will be taken to the Box website, which is a secure and confidential way to send your information to ETF. You don’t need an account with Box to submit forms with this link. Basic contact information is required in case the form is not readable.

After you submit, you'll see "Success! Your file has been submitted." 

It will take a few days to be imaged into your records, at which point ETF staff will be able to view your document. If you have any questions, please contact ETF at 1-877-533-5020.

Submit your completed application securely here.

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