Senior Care Application Form
Payment Authorization Form (Choose your method of monthly payment)
Form B – Credit Card Deduction
Instructions for Printing:
The USC Senior Care application is currently set to 8 x 14 (legal size) paper, it can be printed on standard 8 x 11 size paper, with the shrink to fit (wording may vary by printer) option on your printer. Please note this is a 2-page form and submission of the entire form is required. If you are unable to print on this 8 x 14 size paper or have additional questions, please contact Health Plans. Guidelines on How to Enroll.