Scott & White Health Plan

SeniorCare Request For Information

SeniorCare is offered by Scott & White Health Plan, a State certified Health Maintenance Organization with a Medicare Cost contract.

Contact First Name:

Contact Last Name: *

Phone: *

Extension:

Email:

Preferred Method of Contact:

Phone

E-Mail

Physical Address

Street: *

City: *

State: *

Zip Code: *

County: *

Mailing Address:

Same as physical address

Different

Mailing Address Information

Street:

City:

State:

Zip Code:

Material Request:

Provider Directory

Summary of Benefits

Automatic Payment System Form (Bank Draft)

SeniorCare Application Packet Application(s)

How Many SeniorCare Application Packets?:

Other Request:

Would you like to be contacted by a SeniorCare Representative?:

Yes

No

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