Free consultations and enrollment assistance. Direct contact is required. Referrals are appreciated, but the referred person must initiate contact. Do not submit another person's information unless authorized to act on their behalf.

Do not submit health information, medical records, Medicare beneficiary identifiers, Medicare numbers, Social Security numbers, payment details, or other sensitive information through this form. Privacy Policy General inquiries only.

Medicare: A separate Scope of Appointment is required before a personalized consultation about Medicare Advantage or Part D plan options, including by phone, video, or in person. General Medicare educational questions do not require a Scope of Appointment. This intake form provides permission to respond and does not authorize enrollment.

Marketplace: Documented consent is required before any account access, application assistance, enrollment work, or financial-assistance work on HealthCare.gov. State-based Marketplaces may require their own authorization, account-association, or consent process. Before any Marketplace application or update is submitted, the applicant must separately review and confirm that the eligibility information and application attestations are accurate. Medicare Scope of Appointment Marketplace Client Consent

Neither linked form is required for a general educational inquiry.

Permission applies only to this inquiry and may be withdrawn at any time. Submission does not authorize application access, changes, or enrollment.