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Complete both sides of this form and return this form and required documentation to CTPF. If you are currently enrolled, you DO NOT need to complete a new enrollment form to maintain coverage. *Effective Date Plan changes made during Open Enrollment become effective January 1, 2014. If you enroll at a different time call Member Services at 312.641.4464 for an effective date. BCBS HMO ILLINOIS MEDICARE PLAN ENROLLEES The BCBS HMO Illinois plan for Medicare eligible members will not be offered i.

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