Permission to Contact

The Centers for Medicare & Medicaid Services (CMS) requires your written permission before a licensed agent can discuss Medicare plan options with you. Completing this form lets us reach out — there is no obligation to enroll.

Full name

Email

Phone

Products I'd like to learn about

Select all that apply.

Medicare AdvantageMedicare Supplement (Medigap)Prescription Drug Plan (Part D)Dental / Vision / HearingHospital IndemnityFinal Expense / Life

Preferred contact channels

Select all that apply.

Phone callText message (SMS)Email

I give permission to be contacted about Medicare and related insurance products by the methods I selected above. I understand I can revoke this permission at any time.

Signature (type your full legal name)

Submitting this form is not an application for insurance and does not obligate you to enroll in any plan.