What is your email?

How familiar are you with Medicare?

What Is Your Name?

Perfect Let's Get Started!

Tell me about your current health insurance

What is your address?

Great!

Now, we have a few questions that we will use to provide plan options in your area

What is your preferred pharmacy?

Let's take a look at your current prescriptions

Have your prescription bottles ready so we know which medications you take to include spelling, dosage and frequency

Please enter your current prescription medications:

Do not include over-the-counter medications, vitamins, supplements, or specialty drugs administered at your doctor's office or facility.

Enter N/A on Prescription 1 only if you are not currently taking any medications

Prescription 1

Prescription 2

Prescription 3

Prescription 4

Prescription 5

Add more prescriptions if needed

Click Next if you have no additional prescriptions

Prescription 6

Prescription 7

Prescription 8

Prescription 9

Prescription 10

Tell us about your Hospitals and Doctors

To provide plan options in your area, we'll need some info on your preferred hospitals and doctors to verify their network status

Do you have a preferred Hospital?

Who is your Primary Care Physician?

Do you have a Specialist?

(List all that apply)

Tell us about your preferences when

it comes to your Medicare plan

We will keep these in mind when providing options in your area

Which Medicare option best suits you?

Do any of these apply to you?

(Select all that apply)

We're almost done!

Just a few more questions before I can contact you

What Is Your Phone Number?

What Is Your Age?

We want to ensure you don't miss any important eligibility deadlines

Let's wrap this up!

The Centers for Medicare and Medicaid Services (CMS) requires agents to document a marketing appointment prior to any sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

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Frequently Asked Questions

What is Medicare, and who is eligible for it?

Medicare is a federal health insurance program primarily for individuals aged 65 or older, but it also covers certain younger people with disabilities or those with End-Stage Renal Disease (ESRD). Eligibility is based on age or specific qualifying conditions.

What is the difference between Medicare Part A and Part B?

Medicare Part A covers hospital stays, skilled nursing facilities, hospice care, and some home health services. Part B covers outpatient care, doctor's visits, preventive services, and medical supplies. Part A is often premium-free if you've paid Medicare taxes, while Part B has a monthly premium.

What is Medicare Advantage (Part C)?

Medicare Advantage (Part C) is an alternative to Original Medicare. It is offered by private insurance companies and includes all benefits of Part A and Part B, often with additional benefits like prescription drug coverage, dental, vision, and wellness programs. It typically comes with different out-of-pocket costs and provider networks.

What is the enrollment period for Medicare?

The Initial Enrollment Period (IEP) is a seven-month window that begins three months before your 65th birthday, includes your birthday month, and ends three months after. There is also an Annual Enrollment Period (AEP) from October 15 to December 7, during which you can make changes to your plan.

What happens if I don’t enroll in Medicare on time?

If you miss your Initial Enrollment Period, you may face late enrollment penalties. For example, for Part B, you could pay a 10% higher premium for every 12 months you were eligible but didn’t sign up, unless you qualify for a Special Enrollment Period due to circumstances like continuing employer coverage.

What is life insurance, and why do I need it?

Life insurance is a contract with an insurance company that provides a lump-sum payment to your beneficiaries after your death in exchange for premium payments. It's essential for providing financial support to your loved ones, covering debts, funeral costs, or replacing lost income.