Please select what you want to discuss with a licensed agent

Signature of Beneficiary or Authorized Representative

By signing this form, you agree to a meeting with a licensed agent to discuss the types of products you checked above. The licensed agent is either employed or contracted by a Medicare health plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. 

Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan.

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