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2023 Client Registration Form
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7
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HIPAA
Compliance
1
Name
First Name
Last Name
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2
Can Medicare Supplements Plus Insurance Agency send text messages to your cell phone if we need to get in contact with you? *Message and data rates may apply.
Yes - I give you permission to send me text messages.
No - I do not give you permission to send me text messages.
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3
Phone Number
Please enter a valid phone number.
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4
Can Medicare Supplements Plus Insurance Agency send you emails about agency-related matters? You can remove yourself from our mailing list at any time?
Yes - I give you permission to email me.
No - I do not want to receive emails from Medicare Supplements Plus Insurance Agency.
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5
Email
example@example.com
Confirm Email
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6
Medicare ID Card - Red, White & Blue Card
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: 10.6MB
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7
Voided Check - Make sure you write the word VOID on the check in big letters.
(OPTIONAL)
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: 10.6MB
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8
Current Insurance Coverage or Medicare Supplement Card
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: 10.6MB
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9
Current List of Prescriptions
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