Hey there! I'm Greg Diaz.

I have a couple of optional questions to help provide you with plan options. Upon completion of this short form, I’ll contact you to discuss plan options in your area!

Please have your prescription bottles ready so we know exactly which medications you take. (Spelling, dosage and frequency are important!)

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual 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 Prescription Drug Plan (PDP) - A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

• Medicare Health Maintenance Organization (HMO)- 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 Preferred Provider Organization (PPO) 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. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.
  

• Medicare Private Fee-For-Service (PFFS) Plan- A Medicare Advantage Plan in which 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. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers
  

• Medicare Special Needs Plan (SNP)- A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions.
  

• Medicare Medical Savings Account (MSA) Plan- MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met.
  

• Medicare Cost Plan- In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan's network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Plans offering a supplemental policy to fill “gaps" in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside of the country. These plans are not affiliated or connected to Medicare.

Hospital Indemnity Products

Plans offering additional benefits for consumers who are looking to cover needs for dental, vision or hearing. These plans are not affiliated or connected to Medicare.

Awesome! You're all set.

• By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone, text, or email regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans. Providing permission does not impact eligibility to enroll or the provision of services.
  

• Clear Choice Insurance Agency, LLC is a licensed health insurance agency and is not affiliated or endorsed by the government or Federal Medicare program. The submission data for this form is encrypted by AWS.
  

• We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please visit Medicare.gov or call 1-800-MEDICARE to get information on all of your options.
  

• Clear Choice Insurance Agency, LLC represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.