Enrollment Information

2016 Enrollment Application

Enrollment Application Instructions for Peach State Health Plan Advantage (HMO SNP)

Step 1: Please fill out all 6 pages of the application.

Step 2: Check appropriate YES/NO box for items 1 thru 5 on pages 2 and 3.

Step 3: Enter Primary Care Physician’s Name

Step 4: Sign and date the enrollment application for Advantage by Peach State Health Plan on page 5.

Step 5: Check any box on page 6 that applies to you.

Step 6: Fax or Mail the original copy to:

Peach State Health Plan Advantage
Attn: Enrollment Dept.
7700 Forsyth Blvd
Clayton, MO 63105


Fax: 1-877-941-1931


If you have any questions regarding this application, please contact Member Services at the number listed below and ask to speak to a licensed insurance agent.

You are not required to speak with a sales agent. You can speak with a Member Service representative to receive plan information.

Member Services 1-877-725-7748 (TTY/TDD 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m.



Last Updated: 09302015