A quick Medicare-required form so we can focus your appointment on the plan types you actually want to discuss. Takes about two minutes.
By signing this form, you agree to meet with a Sales Agent to discuss the products you checked above. The Sales Agent is either employed or contracted by a Medicare 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. All information you provide on this form is confidential.
To verify this electronic signature, submission details including the date and time, your IP address, and device and browser information are recorded with this consent.
A signed PDF will be generated, archived, and emailed to your agent with a copy attached to your record. You'll receive a confirmation on this page.
Medicare Health Maintenance Organization (HMO) plan — A Medicare Advantage plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan's network (except in emergencies).
Medicare HMO point-of-service (HMO-POS) plan — Provides all Original Medicare Part A and Part B coverage; may cover Part D. HMO-POS plans may allow some services out of network for a higher copay or coinsurance.
Medicare preferred provider organization (PPO) plan — Provides all Original Medicare Part A and Part B coverage; may cover Part D. PPOs have network doctors, providers, and hospitals, but you can also use out-of-network providers, usually at a higher cost.
Medicare private fee-for-service (PFFS) plan — You may go to any Medicare-approved doctor, hospital, and provider that accepts the plan's payment, terms, and conditions and agrees to treat you. Not all providers will. Some PFFS plans have networks; you usually pay more to see out-of-network providers.
Medicare Special Needs Plan (SNP) — A benefit package designed for people with special health care needs (dual-eligible for Medicare and Medicaid, nursing-home residents, or certain chronic conditions).
Medicare Medical Savings Account (MSA) plan — Combines a high-deductible health plan with a bank account. The plan deposits money from Medicare into the account, which you can use to pay medical expenses until your deductible is met.
Medicare cost plan — You can go to providers both in and out of network. Out-of-network Medicare-covered services are paid under Original Medicare; you'll be responsible for Medicare coinsurance and deductibles.
Medicare prescription drug plan (PDP) — A standalone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare PFFS plans, and Medicare MSA plans.
Medicare Supplement (Medigap) Products — Insurance plans that help pay some of the out-of-pocket costs not paid by Original Medicare Part A and Part B, such as deductibles and coinsurance for Medicare-approved services.
Dental, vision, hearing products — Plans offering additional benefits for consumers looking to cover dental, vision, or hearing. These plans are not affiliated with or connected to Medicare.
Hospital indemnity products — Plans offering additional benefits payable to consumers based on their medical utilization; sometimes used to defray copays or coinsurance. These plans are not affiliated with or connected to Medicare.