Medicare- Permission to Contact Form

Please Contact Me About Medicare Plans

Name

First Name Last Name

Date of Birth

Date

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Telephone

Is this a mobile device?

Yes No

May We Text You?

Yes No

Are you Medicare Eligible?

Yes No

Medicare Eligibility

I am not eligible to enroll before October 15th, please contact me between October 1 and Not Sure

I am interested in plan information for the following (check all that apply): (plan availability may vary by location)

Prescription Drug Plans Medicare Supplement Plans Medicare Advantage Plans Dental Plans Hospital Indemnity Plans

Email Address

By providing my e-mail address or telephone number, / agree to allow a licensed sales representative to contact me regarding information related to Medicare health plans and health insurance plans, products, services and/or educational information related to health care.

Signature

Clear

Today’s Date

Date

According to Medicare rules, we need your permission to contact you to discuss your Medicare plan options. By accepting this form, you are agreeing to a sales telephone call or an email from a licensed sales agent to discuss the specific types of products above. The person who will be discussing plan options with you is with or contracted by a Medicare health plan or prescription drug plan that is not the Federal Government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.