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How To Complete Your Enrollment Application

NMIADA Members

Please click on ONLINE ENROLLMENT to fill out your enrollment application.
Please choose one of the four plans chosen for NMIADA members.
Please complete all sections of your enrollment application.
Please submit payment with your application.

Online Enrollment

Online Enrollment Made Easy for NMIADA Members

As a second option, you may submit your paper enrollment and payment through our secure email or secure fax.

NMIADA Member Paper Enrollment Application

ACH PAYMENT FORM

1 - Open your NMIADA Member Paper Enrollment Application and ACH Payment Form by clicking on the NMIADA Member Paper Enrollment Application and ACH Payment Form above.

2 - Fill out your NMIADA Member Paper Enrollment Application and ACH Payment Form. Make sure you fill out all of the required fields.

3 - Please save your completed enrollment application and completed ACH Payment Form as a new file with your first and last name. (Example, NMIADA Enrollment Form John Smith).

3a - Once completed, please attach your completed enrollment application and your ACH Payment Form and email it to the following POC: Alejandra@fivepointsmecplan.com

4 - Alternatively, you may fax your completed enrollment application and completed ACH Payment Form to the following fax number: 915.519.0261

5 - You may mail your completed enrollment application and completed ACH Payment Form to the following address:

Five Points Health Benefit Plans, LLC

6006 North Mesa Street - Suite 108

El Paso, Texas 79912

We have created a video to help you easily enroll for your mobile phones or tablet.

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