Just for Seniors - Application Form
Yes! I want to become a Just for Seniors member
I understand that the membership program is not an HMO or a Medicare supplemental insurance product. Medicare is not a requirement for this free program. Adequate hospital coverage is my responsibility.
Primary member name:________________________________________________
Gender: ___ Male ___ Female
Day phone: (_____) ______-__________
Send us your application! Print out this form and mail to:
Just for Seniors
LLUMC East Campus
25333 Barton Road
Loma Linda, CA 92354
Questions? Email firstname.lastname@example.org.