Apply to Senior Advantage

Senior Advantage is only available at Shands AGH. To become a member, you must have major medical insurance (group or individual) or Medicare and a Medicare supplemental policy.

To become a part of Senior Advantage, please fill out the form below.

Applicant Information

* Title
*First name
Middle inital
*Last name
*Street address
*City
*State
*Zip code
E-mail

*Social security #
*Telephone
*Sex
*Birth date	(mm/dd/yyyy)
*Race
*Marital status

Personal Information

Are you a previous patient at Shands AGH
Under what name?

Spouse Information

First name
Middle name
Last name
Are you at the same address?
Birth date	(mm/dd/yyyy)

Insurance Information

Medicare
*Medicare claim number

Insurance Information
Shands HealthCare will accept and bill your Medicare and (1) supplemental insurance company. If you come to the hospital, bring your Medicare and insurance cards with you. Pre-certifcation or Second Opinions requirements must be completed before admission (if required by your insurance).
*Do you have supplementary insurance?
*What type is it?
*Policy / certificate number
*Insurance company name
* Billing address
*Insurance company phone number
*Policy holder first name
*Policy holder last name

I certify that all the information provided in this form is correct.

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