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Medicare Consent to Contact
By completing and submitting the requested information in this form, you agree to allow a licensed sales representative to contact you regarding information related to Medicare health plans and health insurance plans, products, services and/or educational information related to health care.

According to Medicare rules, we need your permission to contact you to discuss your Medicare plan options.

The person who will be discussing plan options with you is with or contracted by a Medicare health plan that is not the Federal Government, and they may be compensated based on your enrollment in a plan.

Submitting this form 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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Please check the box that you agree to be contacted after submitting this form