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I have a couple of optional questions to help provide you with plan options. Upon completion of this short form, I’ll contact you to discuss plan options in your area!

By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone, text, or email regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans. Providing permission does not impact eligibility to enroll or the provision of services.

is a licensed health insurance agency and is not affiliated or endorsed by the government or Federal Medicare program. The submission data for this form is encrypted by AWS.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please visit Medicare.gov or call 1-800-MEDICARE to get information on all of your options.

represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.

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