Download the following form and follow the directions below to complete your application.

Click Here to Download >> MCO Brochure

Click Here to Download >> MCO Application

Application Instructions for NAIB/Med Choice One Application

1. Print the MCO Brochure and keep it for your records
2. Print both pages of the application. Review and keep page two for your records
3. Complete all questions and sections on page one of the application. Please print legibly
4. Sign the application in three places: 1st Member Signature / 2nd Member Signature / Bank Draft Authorization
5. Keep a photocopy of your completed application for your records

HELPFUL TIPS:

• Indicate the Month you wish the coverage to begin (effective date)
• Indicate your preferred draft date
• Select your preferred method for your initial payment, check or credit card
• The Initial Payment is the total of the appropriate fees and dues for your selections, plus the one-time $25.00 Processing / Activation fee.

If you choose to pay the Initial Payment by Check,

Fax to Med Choice One:

• your completed Application
• a photocopy of your Check (Made payable to Med Choice One)
• a photocopy of your Voided check to Med Choice One
• Then, mail your Original check and a photocopy of your Application to MCO on the same day that you faxed the application. (Mark on the application – “Previously Faxed on xx/xx/xxxx”)

Med Choice One, LLC
Attn: New Applications
5619 DTC Parkway Suite #920
Greenwood Village, CO 80111

OR…

If you choose to pay the Initial Payment by Credit Card,

Sign the application a 4th time in the Credit Card Authorization block with complete information on the credit card. If the name on the credit card is different from that of the member, write the name that appears on the credit card in the computation block under “TOTAL AMOUNT DUE TODAY”. A photocopy of both sides of the credit card will clear up any questions.

Fax to Med Choice One:

• your completed Application with 4 signatures
• a photocopy of your Voided check

PLEASE NOTE:

Med Choice One will review your application for completeness and accuracy. We cannot process unclear or incomplete applications until the missing or unclear information has been gathered. This may increase the approval time if we need to contact you.

Please contact us if you have any questions regarding the application or the application process. You may reach us at 720-200-2825 (local) or at 888-83-4MCO (4626) (toll-free) Monday through Friday between 9:00 AM and 5:00PM.

You may also mail us at info@medchoiceone.com