Enrollment Portal
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New enrollment submission
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Enrollment PDF
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Signed enrollment form · PDF only
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Date
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Client name
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MBI
✓
State
✓
Phone number
✓
SEP
✓
Agent
✓
Our plan
✓
New Plan Name
✓
SF code
✓
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✓ Done
Old plan
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Email
✓
Team Notes for Sale
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Selling Point / Why This Plan Is Better
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Medicaid Number
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Medicaid Level
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Full Medicaid (Dual)
QMB Only
QMB+
SLMB
SLMB+
QI
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LIS Level
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LIS Level 1 (Full)
LIS Level 2
LIS Level 3
LIS Level 4
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Doctors In / Out of Network
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Medications Covered
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HRA Completed
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Extra Notes
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Agent Notes Preview (auto-generated)
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