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Tell me about your current health insurance

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

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

Click Next if you don't have additional prescriptions

Click Next if you don't have additional prescriptions

Tell us about your Hospitals and Doctors

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

(Select all that apply)

Just a few more questions before I can contact you

(Include your area code)

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

The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any face-to-face 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.