Please have a licensed agent contact me to discuss Medicare options

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Disclaimer:

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. By entering your information below and clicking Submit, you are giving permission to have a licensed sales agent contact you by email, telephone or cell phone to provide additional information about products and services as well as acknowledging the following information:

  • The consumer agrees to receive telephonic sales and marketing calls and text messages using an automated system for the selection or dialing of telephone numbers, automated voice calls, AI generative voice calls, prerecorded messages played when a connection is made, or prerecorded voicemail messages;
  • Providing permission does not impact the consumer's eligibility to enroll;
  • The consumer can change his or her permission preferences at any time by contacting MedicareAndMe; and
  • The consumer provides this consent even if the consumer's number is listed on a Do Not Call registry.

Data use charges and rates from your cellular carrier may apply.
Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. This form does not constitute a Scope of Appointment.

The Centers for Medicare and Medicaid Services requires agents to document the scope of 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.

Medicare Required Disclaimers

  • We do not offer every plan available in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
  • Medicare & Me is a licensed and certified representative of a Medicare Advantage organization with a Medicare contract. Enrollment in any plan depends on contract renewal. is a licensed and certified representative of Medicare Advantage organizations that has a Medicare contract. Enrollment in any plan depends on contract renewal.
  • By dialing the number you will contact a "licensed sales agent" or “licensed insurance agent”.
  • To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.
  • Every year, Medicare evaluates plans based on a 5-star rating system. The Star Ratings apply to contract year 2024 .

Hours of Operation: M-F, 8-5

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Last Updated: 09/05/2024