2015 Enrollment Applications

Your decision to enroll in one of Quality Health Plans of New York's Medicare Health Plans is an important choice from which you may reap rewards for years to come.  Below are information and links to  the actual enrollment applications.  

 

First, please view the approved enrollment applications so you will know what kind of information you will need to provide.  You can download the files, print them, fill them fill out and mail them to the address listed below.  Note that you can save the document to your local computer.

 

You must also download and complete the Attestation of Eligibility.  If you require any assistance, please call customer service.


2015 QHP New York Enrollment Applications
2015 Application for Advantage Premium Plus NY
Mail To:
Quality Health Plans of New York
2805 Veterans Memorial Highway, Suite 17
Ronkonkoma, NY 11779
Click Here to View Application
2015 Application for All Other Plans
Mail To:
Quality Health Plans of New York
2805 Veterans Memorial Highway, Suite 17
Ronkonkoma, NY 11779
Click Here to View Application
Attestation of Eligibility
Mail To:
Quality Health Plans of New York
2805 Veterans Memorial Highway, Suite 17
Ronkonkoma, NY 11779
Click Here to View Application