Brokers - Enroll a Member
Enter your Writing Number and Choose A Plan
Before making an enrollment decision, it is important that you fully understand our benefits and rules.
If you have any questions, you can call and speak to a customer service representative at 877-384-1241 (TTY: 711)
We are open
8:00 am to 8:00 pm Monday – Friday from April 1 – September 30
8:00 am to 8:00 pm Monday – Sunday from October 1 – March 31
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.
Llame al 1-877-384-1241 (TTY: 711)
Please read and accept below
By submitting this enrollment application electronically and clicking on the "acceptance of Attestation" button below, I attest that this prospective member enrollment application was completed in compliance with all CMS Medicare marketing and enrollment guidelines for enrolling a prospective members well as all applicable state and federal laws, rules, and regulations. I further attest that all information submitted on the enrollment application is true and correct to the best of my knowledge.
I attest that the prospective member has sought my assistance in completing and submitting this enrollment application and that I have explained to the prospective member that I am an agent/broker and that I may be paid based on the prospective member's enrollment with Clear Spring Health.
I attest I have collected and will retain (for 10 years) the proper Scope of Appointment in accordance with current CMS Medicare guidelines and Clear Spring Health policies.
I attest that I have not engaged in fraud or any fraudulent conduct in connection with the preparation and submission of this enrollment application. I understand that there may be a penalty for providing false information on this enrollment application.