Senior Care Application

Medical West Senior Care Application

APPLY TODAY!

To enroll in the Medical West Senior Care program, print and fill out the following form and mail it with your $30 membership fee to:

Senior Care
995 9th Avenue SW
Bessemer, AL 35022

Mr.     Mrs.   Ms.     

Name:

Address:

City:   

State:    Zip:    

Phone:

Date of Birth:

Do you have Medicare Parts A and B?

Yes    No

Name of Primary Insurance:

Primary Care Physician's Name:

Physician's Phone Number:

 

Please allow approximately two weeks to receive your Senior Care membership card. Thank you!