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Enroll by Mail or Fax

[Filling out a paper application is easy!  Below are all of the instructions you need.  If you need help filling out the application, please contact us.  We are here to help!

Enrollment Application Instructions

  1. Download and print the below application for your state:
  2. Please fill out all 7 pages of the application.
  3. Check either YES or NO box for items 1 through 5 on pages 2 and 3.
  4. Enter your Primary Care Physician's name.
  5. Sign and date the enrollment application for Ascension Complete on page 5.
  6. Check any box on page 6 that applies to you.
  7. Submit your application via mail or fax.

Our enrollment applications are available for free in other languages or format. Please contact Member Services. We are here to help!

Application Submission Options

Mail Your Application

Send your application to:

Medicare Enrollment Department
P.O. Box 2020
Farmington, MO 63640-2011

Fax Your Application

Fax your application to:

1-844-222-3180