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You are about to fill out an application for a Fidelis Medicare Advantage Plan. By filling out this application, you will be sending an actual enrollment election form to Fidelis Care.
 
After completing this form, you will be enrolled in your chosen Medicare plan if the enrollment is approved by the Centers for Medicare and Medicaid Services (CMS).
 
Fidelis Care will notify you via mail of your acceptance or denial following the submission of the enrollment to CMS.
 
If you are applying to a Fidelis Dual Advantage program, an additional form will need to be signed by you and sent to your county. After you have completed the Medicare Advantage application, we will contact you to have the additional form signed. Fidelis Care will be unable to submit your application to Medicare until you return the signed Medicaid Advantage form to Fidelis Care.
 
Thank you for applying to become a member of Fidelis Medicare Advantage. We look forward to serving as your partner in good health.
 
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