TotalCare - Permission to Contact Inquiry Form

Completing for:

Name:

First NameLast Name

Permanent residence address:

Street Address

Street Address Line 2

CityState

Zip Code

Phone number:

Please enter a valid phone number.Format: (000) 000-0000.

Email:

Preferred method of contact:

Currently Medicare eligible:

If no, when will you be eligible?

If you’re completing this form for someone else, complete the section below.

Your signature certifies that you’re authorized under State law to fill out this participation form and have documentation of this authority available if Medicare asks for it.

Name:

Relationship to participant:

Phone number:

Please enter a valid phone number.Format: (000) 000-0000.

Email:

example@example.com

Signature:

By giving my contact information, I agree to allow a licensed sales representative to contact me about information related to Medicare options or to enroll in the TotalCare plan.

I understand that the person who will be discussing TotalCare D-SNP plan with me may be compensated based on my enrollment in the plan.

This permission to contact is valid for 12 months.

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