Skip to main content

The Medicare annual enrollment period runs from October 15 through December 7. Start the online enrollment process below. By completing this process, you will submit an actual enrollment application. To enroll with the help of a licensed representative please call 800-983-7587 or email medicaresalesteam@networkhealth.com. You may also print and fill out an Enrollment Form. Send your completed enrollment application to

Network Health, Attn: Medicare Enrollment
1570 Midway Pl.,
Menasha, WI, 54952
Options loading...

Enrollment Request Form to Enroll in a Network Health Medicare Advantage Plan

Who can use this form?
People with Medicare who want to join a Medicare Advantage Plan

To join a plan, you must:
  • Be a United States citizen or be lawfully present in the U.S.
  • Live in the plan’s service area
Important: To join a Medicare Advantage plan, you must also have both:
  • Medicare Part A (Hospital Insurance)
  • Medicare Part B (Medical Insurance)
When do I use this form?
You can join a plan:
  • Between October 15 through December 7 each year (for coverage starting January 1)
  • Within three months of first getting Medicare
  • In certain situations where you’re allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?
  • Your Medicare Number (the number on your red, white, and blue Medicare card)
  • Your permanent address and phone number

Note: You must complete all items in Section 1. The items in Section 2 are optional — you can’t be denied coverage because you don’t fill them out.

Individuals experiencing homelessness
  • If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., social security checks) may be considered your permanent residence address.
Reminders:
  • If you want to join a plan during fall open enrollment (October 15–December 7), the plan must get your completed form by December 7.
  • If you have a monthly premium, your plan will send you a bill for the plan's premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?
Send your completed and signed form to:
Network Health
Attn: Medicare Enrollment
1570 Midway Pl.,
Menasha, WI 54952

Once we process your request to join, we’ll contact you.

How do I get help with this form?
Call Network Health Medicare Advantage Plan at 800-983-7587. TTY users can call 800-947-3529. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. 
County select loading...
Enrollment form loading...

View the Medicare Advantage Summary of Benefits for benefits and cost information. See our 2025 Star Rating Information for Network Health PPO Medicare Advantage Plans and Network Health Prime (MSA). (Medicare evaluates plans based on a Five-Star rating system. Star Ratings are calculated each year and may change from one year to the next)

Medicare beneficiaries may also enroll in Network Health through the CMS Medicare Online Enrollment Center located Medicare.gov. Please contact Network Health Medicare Advantage Plans if you need information in another language or format.

En español: Llame a Network Health Medicare Advantage Plan al 800-983-7587 (TTY 800-947-3529) o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.

Individuals experiencing homelessness: If you want to join a plan but have no permanent residence, a Post Office Box, an address of a shelter or clinic, or the address where you receive mail (e.g., social security checks) may be considered your permanent residence address.

OMB No. 0938-1378 Expires: 6/30/2026
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1378. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. IMPORTANT Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.