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Geisinger Gold Medicare Advantage
Geisinger Gold enrollment
Authorized agent or broker
As an authorized representative of the beneficiary you need to complete the following information.
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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