* According to Medicare rules, we need your permission to contact you to discuss your Medicare plan options. By completing this form, you are agreeing to a sales telephone call or an email from a licensed sales agent to discuss the specific types of products above. The person who will be discussing plan options with you is with or contracted by a Medicare health plan or prescription drug plan that is not the Federal Government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

By providing my e-mail address or telephone number, I agree to allow a licensed sales representative to contact me regarding information related to Medicare health plans and health insurance plans, products, services and/or educational information related to health care.