FILL OUT THE FORM BELOW

We require your consent before contacting you to go over your Medicare plan alternatives, given Medicare regulations. By filling the form below , you consent to a licensed insurance agent from Benefits & Care, to contact you by mail, phone, sms or email to discuss particular products. The person who will talk to you about your plan alternatives works for or is employed by a Medicare health plan or a prescription drug plan that is not a Federally-sponsored program, and they might receive payment based on your participation in a plan. Your current enrollment in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan will not be impacted by signing this form, nor will it enroll you in one.