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Geisinger Gold Medicare Advantage

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Geisinger Gold enrollment

Authorized agent or broker

As an authorized representative of the beneficiary you need to complete the following information.

Asterisk denotes a required field

Last name

Agent or broker ID

I certify that I have completed all required Medicare training, testing and certifications prior to submitting this application. I also certify that if this enrollment is as a result of a face-to-face, individual appointment with a prospective member that a scope of appointment is on file with Geisinger Gold or will be faxed/mailed to Geisinger Gold enrollment within 48 hours after the online application is submitted.

Y0032_18270_1_M File and Use 10/1/18

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Geisinger Health Plan may refer collectively to Geisinger Health Plan, Geisinger Quality Options Inc., and Geisinger Indemnity Insurance Company, unless otherwise noted. Geisinger Gold Medicare Advantage HMO, PPO, and HMO D-SNP plans are offered by Geisinger Health Plan/Geisinger Indemnity Insurance Company, health plans with a Medicare contract. Continued enrollment in Geisinger Gold depends on annual contract renewal. Geisinger Health Plan Kids (Children’s Health Insurance Program) and Geisinger Health Plan Family (Medical Assistance) are offered by Geisinger Health Plan in conjunction with the Pennsylvania Department of Human Services (DHS). Geisinger Health Plan is part of Geisinger, an integrated health care delivery and coverage organization.