Do you have VA health and prescription benefits? *

*Yes

*No

Do you currently have Medicare A & B coverage? *

*Yes

*No

This offer is for people with active Medicare A & B

Do you purchase your prescription medications through the VA system? *

*Yes

*No

Is your primary care provider a VA healthcare provider? *

*Yes

*No

Do you receive Medicaid benefits through your state in addition to VA benefits? *

*Yes

*No

Provider and Medication Details

Do you see any healthcare providers outside of the VA system? *

I do not see any providers outside of the VA system.

I am seeing providers outside of the VA system.

Please list any providers you see outside of the VA system. *

Example Input: Dr. Amy Wilson – Primary Care, Dayton Family Clinic

Do you purchase any medications outside of the VA system? *

All prescriptions are filled through the VA pharmacy.

I purchase medications outside of the VA system.

Please list the medications you purchase outside of the VA system. *

Example Input: Lisinopril 20mg – Walgreens, Dayton OH

Personal Information

First Name *

Last Name *

Phone *

Mailing Address. No P.O. Box

Street Address *

City *

State *

Country

Zip code *

Trusted Form Cert Url

IP Address

Trusted Form Ping Url

Main Applicant Date of Birth: *

Social Security Number (We need this to verify your application) *

* Please Provide Valid Social Security Number

Please Provide Valid Social Security Number *

Social Security Number Verification Status

Gender *

Disqualify Lead

Disqualify

By signing below, I confirm that I am providing a Scope of Appointment for the Assigned agent to discuss: *

Medicare Advantage (MA-Only)

I understand that this Medicare Advantage (MA-Only) plan will not cover services provided at VA facilities. Emergency or urgent care outside the VA will be covered under the plan’s network benefits. *

Clear

Medicare Consent and Acknowledgement

Licensed Health Insurance Agent Notice

I understand I am consenting to receive assistance from a licensed health insurance agent assigned to my case. The assigned agent will be properly licensed/appointed and identified to me prior to any enrollment activity.

I confirm that all personal and Medicare eligibility information I provide is accurate to the best of my knowledge. This information will be used to evaluate and discuss Medicare plan options consistent with applicable CMS marketing guidelines.

Agent of Record (AOR) Consent

I appoint the assigned licensed health insurance agent as my authorized assigned health insurance agent for Medicare insurance matters, including plan discussions, enrollment assistance, and policy changes. I may revoke or modify this consent at any time.

Scope of Appointment (SOA)

I consent to discuss the following Medicare-related products:

Medicare Advantage (Part C)
Medicare Prescription Drug Plans (Part D)
Medicare Supplement Insurance (Medigap)

This SOA is valid for up to 12 months unless I revoke or modify it sooner. No other products will be discussed unless a new SOA is completed.

HIPAA / HRA Authorization

I authorize collection and use of my health information for plan evaluation and enrollment support, including health risk assessment (HRA), conditions, medications, and preferred doctors. My information will be handled confidentially and in accordance with applicable privacy and data protection laws. I may revoke this authorization at any time, except to the extent actions have already been taken in reliance on it.

Medicare Claim ID Number / Eligibility Lookup Authorization

If I do not provide my Medicare Claim ID Number, I authorize the assigned agent or their service providers to securely verify or look up my Medicare Claim ID Number and Medicare eligibility using identifiers such as my name, date of birth, and my Social Security Number. Any such lookup will be used solely to evaluate my plan options and/or complete enrollment.

Marketing & Communication Standards

All marketing communications will follow CMS marketing rules, including prohibitions on misleading statements and door-to-door solicitation. I understand that plan details, benefits, and costs vary by location and eligibility and will be explained to me before any enrollment.

Third-Party Marketing Organization (TPMO) Disclaimer

We do not offer every plan available in your area. Any information provided is limited to the plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. Plan availability varies by location and eligibility. The agent may be compensated by insurance companies for enrollments; this does not affect your premiums or benefits.

TCPA Consent to Contact

By submitting this form, I agree that a licensed health insurance agent may contact me by phone, text (SMS), or email, including via automated technology, at the contact information I provide—even if my number is on a state or federal Do Not Call list. Message and data rates may apply. I can opt out at any time.

No Guarantees & Enrollment Implications

I understand there are no guarantees of eligibility or enrollment outcomes. Any changes to my current coverage—including termination or modification—will be explained before enrollment, and I will be asked to confirm my understanding.

Accessibility & Equity

Interpreter services and alternate formats are available upon request to support equitable and accessible communications.

Electronic Signature (ESIGN)

By signing or submitting electronically, I agree to the terms above and consent to conduct business electronically. I understand that my consent, signatures, and acknowledgements will be captured with date/time and may include device/IP information.

Disclaimer

Built to align with CMS marketing and data standards. Not affiliated with, endorsed by, or acting on behalf of the U.S. government, the Centers for Medicare & Medicaid Services (CMS), or any Medicare carrier.

I authorize my Assigned agent or plan representative to contact the VA or Medicare to verify my eligibility or claims status if required for enrollment. *

Clear

Last Step before you can see your customized plan and benefits:

Do you currently have your Medicare claim ID number available with you right now? *

*Yes

*No

Selected Plan Image

Plan ID

Plan Name

Plan type

Plan Carrier Name

Benefits Url

Brochure Url

Plan 2 Id

Plan 2 Brochure Url

Plan 2 Premiums

Plan 2 Benefits Url

Plan 2 Name

Plan 2 Type

Plan 3 Brochure Url

Plan 3 Type

Plan 3 Carrier Name

Plan 3 Id

Plan 2 Carrier Name

Plan 3 Name

Plan 3 Benefits Url

Plan 3 Premiums