Medicare Sales Consent Form
Please complete this form to provide your contact details, Medicare plan interests, and consent for communication regarding Medicare plan options.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Are you currently enrolled in Medicare?
*
Yes
No
Which type of Medicare plan are you interested in?
*
Medicare Advantage (Part C)
Medicare Supplement (Medigap)
Prescription Drug Plan (Part D)
Not Sure
Other
How do you prefer to be contacted?
*
Phone Call
Email
Text Message
Preferred time to be contacted
Please Select
Morning (8am - 12pm)
Afternoon (12pm - 5pm)
Evening (5pm - 8pm)
Anytime
Do you permit a licensed agent to follow up with you about Medicare plan options?
*
Yes, I permit follow-up
No, I do not permit follow-up
I acknowledge that I am requesting information to discuss Medicare plan options.
*
I acknowledge and wish to proceed
I do not wish to proceed
Submit Consent
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