MediSunONE Election Form

Completing the Application Process

1. Please complete the application using black ballpoint pen, and press firmly. There are detailed instructions on the next page. Please read the instructions and statements carefully. If you have any questions, please call MediSun Health Plan at (623) 974-7430, or 1-800- 446-8331 if you are outside Maricopa County, call our TTY line at (623) 974-7440.

2. Please make a photocopy of your Medicare Health Insurance card and include it with the election form.

3. Sign and date the election form upon completion. If you are the applicant’s representative,
you must have a Durable General Power of Attorney or court-ordered Legal Guardianship
to sign on his / her behalf. Please provide a copy of the paperwork with the application.

4. Return the completed forms and a copy of your Medicare card to MediSun Health Plan
PO Box 1489, Sun City, AZ 85372-1489. Print a copy of your election form for your records. In most cases, we will acknowledge the receipt of your application in writing before the effective date.

It’s as simple as that to enroll in MediSunONE!
Thank you for choosing MediSun Health Plan

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