Medicare Info Form

Medicare Info Request Form

By filling out this form, you give the staff at 12 Months to Medicare permission to send you info and/or contact you by email, phone, text or however you choose by filling in below. Because only a licensed agent may give you plan advice, we must also give you required Medicare disclosures found at the bottom of the page. This form is hosted a secure platform and emailed to Info@12MonthsToMedicare.com If no response or questions, call: 423-202-8594
Beneficiary Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender
Physical Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Mobile Number / Texting
Phone Number
COUNTY of the State you reside*
IF you have a MAILING Address different than your physical address, please type it below:
When did/does your Part B start?*
Do You have your Medicare card yet?
Do you/will you have both parts A and B?
Are you currently on a health plan through a work/union plan? (Yours or Spouse) If so, when will that plan end?
Are you going on Medicare due to Disability (SSDI)?
Will you also have State Medicaid?
Do you know if you qualify for Low Income Subsidy?
Based on reading chapter/month 5 and 6, which type of plan are you considering? A Supplement? Advantage Plan? or not sure yet?
Because you will need a drug plan to avoid a drug penalty (either as a separate PDP or within an Advantage Plan), please list your drugs below so we can being research. List like this: Exact name of drug - dosage - times per day
Medicare Disclosures:

By filling out this form, you agree that a licensed sales representative may contact you by phone or email to provide information about Medicare Plans including Advantage, SNP Dual, Part D or Supplements. This is an insurance sales solicitation. Not affiliated with US government or Federal Medicare program. Some exclusions and limitations may apply. Not all products/services are available in all areas. MEDICARE REQUIRED NOTICE: “We may not offer every plan available in your area. Any information we provide is limited to those plans we do offer. You can contact Medicare.gov or 1–800–MEDICARE to get information on all of your options.” All Calls regarding and discussing Advantage Plans and/or PDP plans are recorded due to Medicare requirements.
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Medicare Info Request Form

Medicare Disclosures: