First, you’ll need to become a JACL member.  Complete the JACL Membership application and make your check payable to: "JACL".  If you are already a current JACL member, please indicate your chapter name on the Blue Shield application.

Next, you’ll need to include a photocopy of your Medicare card showing coverage of both Parts A and B.  Medicare Part D is not necessary for our Senior plans.  If you are applying more than six months after receiving your Medicare card, then you’ll also need to provide specific information regarding a complete physical examination performed within the last two (2) years.

Finally, return the completed applications, check and Medicare card photocopy to our office at 220 Sansome Street, Suite 1360, San Francisco, CA 94104. Remember to include the following:

	JACL Membership Application
	Check payable to: "JACL"
	Blue Shield Application
	Physical Exam information (if more than six months after receiving Medicare card)
	Photocopy of Medicare card showing Parts A&B

If your application is approved by Blue Shield of California, then you will be notified of the effective date and billed.  Incomplete or illegible applications are returned, so be sure to carefully review the entire form and print clearly in ink (or type).  Don't forget to sign your application.