Enrollment Forms
There are several Health Plan Enrollment Forms currently in use. The correct form to use is based on the population it is designed to serve.
- DHS-4106A (PDF) is used by clients, including those enrolling in PMAP and MSC+.
- DHS-4106C (PDF) is used when enrollees are age 65 or older or when at least one member of the household qualifies to enroll in MSHO.
Enrollment forms used to enroll in SNBC are currently only available through the health plan that provides the program and are not available on eDocs.
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Managed Care - Enrollment Process