Agency Consent to Contact Medicare

I understand that completion of this form is not required but it is needed if I’d like additional information regarding plan options or contact from a licensed Medicare sales agent. I understand that I am not required to complete this form and have done so at my discretion.

By submitting this form, you are requesting to have a licensed insurance sales agent contact you by telephone, email or cell phone to provide additional information about products and services.Your consent is voluntary and allows us to contact you via text messaging, artificial or prerecorded voice messages, or automatic dialing for marketing purposes. You may contact us to change your preferences at any time. Changing your preferences will not affect your eligibility for Humana benefits and enrollment, payment for coverage of services, or ability to get treatment. Data use charges and rates from your cellular carrier may apply.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Do we have your permission to communicate via text with you at this number?*

YesNO
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Current Medical Plan?
Name of Medical Provider?
Number of Prescriptions?
Medicare Number
Should be Empty:

I understand that completion of this form is not required but it is needed if I’d like additional information regarding plan options or contact from a licensed Medicare sales agent. I understand that I am not required to complete this form and have done so at my discretion.