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Allwell Paper Application

Filling out a paper application is easy!  Below are all of the instructions you need.  If you need help filling out the application, call us to speak to a licensed sales agent.  We are here to help!

Enrollment Application Instructions

  1. Download and print the below application for your state
  2. Please fill out all 7 pages of the application.
  3. Check either YES or NO box for items 1 through 5 on pages 2 and 3.
  4. Enter your Primary Care Physician's name.
  5. Sign and date the enrollment application for Allwell on page 5.
  6. Check any box on page 6 that applies to you.
  7. Submit your application via mail or fax.

Our enrollment applications are available for free in other languages or format.  Please call us to speak to a licensed sales agent. We are here to help!

Application Submission Options

Mail Your Application

Send your application to:

Medicare Enrollment Department
P.O. Box 2020
Farmington, MO 63640-2011

Fax Your Application

Fax your application to:

1-844-222-3180