Enrollment Forms 2009

Do not complete the enrollment form unless you have already reviewed the Summary of Benefits.

In this section you will find the Enrollment forms for each of our plans. If you have already reviewed the Summary of Benefits and wish to enroll now, just click on the plan below to print out the Enrollment Form.

Please complete each form, but do not sign it until you read the second page (back of the form). Once you have read the second page and agree with the information provided, then sign and date the form and mail it to:

Enrollment Department
P.O.Box 195080
San Juan, PR 00919

PPO
• First+Plus Advantage
• First+Plus Advantage Plus
• First+Plus Advantage Premium

HMO
• First Care Plus
• First+PlusTitanio
• First+Plus Complete

PDP
• Pharma Plus
• Pharma Premium

Employer Group Health Plans
PPO
• First+PlusGobierno Premium
• First+PlusGobierno Premium UPR

PDP
• PharmaGobierno