You have Javascript and/or stylesheets
disabled. Turning off Javascript or stylesheets disables the interactive functions
of this page and prevents the definitions of the various terms underlined below
from appearing when you place your mouse cursor over them.
Instructions
- Please click on the application and fill it out online.
- Print a copy of your completed form and don't forget to sign it before submitting.
- (Optional) Print out the Surepay form and complete by hand.
Hints
- Enrolling yourself and your spouse? Both of you will need to fill out a separate enrollment form.
- Select the plan you want.
- Decide if you want your premium deducted from your personal checking, savings or money market account (you will need to fill out the Surepay form listed below).
- Answer all questions so we can process your application without delay.
(79k) 2010 Enrollment Form (PDF)
(42k) Optional: 2010 Surepay Form (Fillable PDF)
Where to mail enrollment and Surepay forms
Asuris Northwest Health
Medicare Membership Accounting MS:S5B
P.O. Box 12625
Salem, Oregon 97309-0625
Where to fax enrollment and Surepay forms
Please fax to this number: 1-888-335-2988.
If you fax your forms to us, you do not need to mail them as well.
Where to call for more information
Please call us at 1-888-734-3623 for answers to questions about applying for coverage. Our hours are 8 to 5 p.m., Monday through Friday, Pacific time. You may also call us at 1-800-541-8981 from 8 a.m. to 8 p.m. seven days a week.
Apply on Paper