Permission to Contact Form v2 07112023

Permission to Contact Form

Please contact me about Medicare and/or other Health Plans
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
Please enter a valid phone number.
Home Number
Please enter a valid phone number.
Office Number
Please enter a valid phone number.
Email
example@example.com
Text Message

YesNo
Medicare Eligible?

YesNo
I'm not eligible to enroll before October 15, please contact me between October 1 and December 7
I'm interested in plan information for the following (check all that apply):

Prescription Drug PlansMedicare Supplement PlansMedicare Advantage PlansDental PlansVisionHearingHospital Indemnity PlansShort Term MedicalInternational Health InsuranceIndividual & Family Health PlansOther
By providing my e-mail address or telephone number, I agree to allow licensed insurance agent, Kitchie McBride, MHA with KM Health Insurance Services 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
Date

MonthDayYear
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.
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