1. Applicant Information
  2. Enrollment Eligibility
  3. Plan Selection
  4. Additional Information
  5. Part A - B
  6. Additional Coverage
  7. Other Drug Insurance
  8. Payment
  9. Confirmation

Medicare Advantage Plan Enrollment

Please complete the form below to start the enrollment process.

Applicant Name & Contact Information

First Name
Middle Initial
Last Name
Applicant Date Of Birth
Phone Number
Cell Phone

Applicant Address

(Physical Street Address Only)

Street Address
Suite, apt, etc.
Zip Code + 4 digits

Medicare Enrollment

Power Of Attorney


This privacy notice discloses the privacy practices for www.vivahealth.com regarding information we collect from our website users. This privacy notice applies solely to information collected by this website.

Information Collection, Use, and Sharing
Viva Health is the sole owner of the information collected on this site. We have access to information that you voluntarily give us via email or other direct contact from you. We will not sell or rent this information to anyone. We will use your information to respond to you regarding the reason you contacted us and/or to process your on-line enrollment application. We will not share any information you submit to us via the website with any third party outside of our organization unless the disclosure is permitted by law.

Your Access to and Control of Information
Viva Health will not use the information you submit to us to contact you regarding matters that do not pertain to your enrollment or coverage in our plan. For information submitted through our online application process or through www.vivahealth.com/medicare, you can do the following at any time by contacting us via the email address or phone number given on our website: See what data we have about you, if any. Change/correct any data we have about you. Express any concern you have about our use of your data.

We take precautions to protect your information. When you submit sensitive information via this website, your information is protected both online and offline. Viva Health continually investigates and evaluates new security technologies and practices. Wherever we collect sensitive information through this website, that information is transmitted to us in a secure way. We also protect your information offline. Only employees who need the information to perform a specific job (for example, enrollment, billing or customer service) are granted access to personally identifiable information. The computers/servers in which we store personally identifiable information are kept in a secure environment.

E-Mail Security
Sending emails via the internet to Viva Health (through the links on this website or otherwise) poses certain risks that you should be aware of. Email messages may pass through private and public networks with varying levels of security which means that your email may not be completely secure (encrypted). Your email system may or may not secure (encrypt) emails, thereby compromising the privacy and integrity of the information. Therefore, we ask that you use your best judgment on what information you send to us via e-mail. If you have personal or confidential information you would like to send to Viva Health, you may want to consider calling, faxing or mailing the information instead of using email. We will preserve the content of emails you send to Viva Health, and if the response contains confidential or protected health information, we will only issue a secure (encrypted) response.

This website contains links to other sites. Please be aware that we are not responsible for the content or privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of any other site that collects personally identifiable information.

For More Information or To Report A Problem.
If you have questions or need additional information, or if you believe we are not abiding by this privacy notice, you may contact Viva Health at 417 20th Street North, Suite 1100, Birmingham, AL 35203 or by telephone at 205-939-1718 (in the Birmingham area) or 1-800-294-7780. Our office hours are Monday-Friday, 8:00 a.m. – 8:00 p.m.

By clicking "I Agree" you acknowledge you have reviewed and accept Viva Health's Web Disclaimer