My Access Forms

My Access is a non-for-profit public service provided without charge.
In order to find out your elegibility and to apply for assistance in the benefits available for you and your family you must go to any of our 2 locations and bring with you the Required Documents listed below.

Be sure to download, fill and send via e-mail to info@erhealplans.com all of the documents listed on the right.

On the day of your visit please bring the following documents with you:
-Social Security Card.
-Florida ID Card (FL Driver's License).
-Documents Supporting you Income (Pay stumps, W-2, 1099, etc).

• Appointment Request Form Document size: 100 Kb
• Recertification Form Document size: 187 Kb
• Registration Form Document size: 190 Kb
• Financial Information Release Form Document size: 100 Kb

Medicare

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or his/her authorized representative).
All information provided on this form is confidential and should be completed by each person with Medicare or by his/her authorized representative.
Click on the document below to download and / or electronically fill the appointment form.

• SOA Confirmation Form Document size: 119 Kb