Agent Referral Form:
REMINDER THAT MHC DOES NOT ACCEPT REFERRALS FOR PDP / PART D CLIENTS ONLY.
Referring Agent Information
Client Information
Client can ONLY be contacted by phone if a permission to contact form is attached to this request or sent by email to: Health@MagellanFinancial.com
Does Client have a spouse that will also need services?
Yes
No
Spouse Information:
Is Client:
*
Turning 65 in the next 6 months
Over 65 & getting ready to retire
Needing an MAPD review for AEP
Wanting to shop their Med Supplement
Other
Current Policy Information:
Please Explain:
Notes/Comments:
If the client consents to being contacted by phone, please upload the permission to contact form here:
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