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Phone number *

Address *

Medicare

Please provide your Medicare information.

Medicare number

The effective date for Medicare Part A

The effective date for Medicare Part B

Doctors

Please introduce us to your Primary Care Physician (PCP).

(PCP) Company name

(PCP) Doctor’s name

(PCP) Phone number

(PCP) ID number

Do you see any Specialists?

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(S) Company name

(S) Doctor’s name

(S) Doctor’s Specialty

(S) Phone number

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Medications Tab

Do you take any prescription medication?

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Please list the name of your prescription

What is the dosage amount?

What is the dosage frequency?

What is your monthly co-pay?

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Submit your information below and we will contact you about your Medicare coverage options.This is a solicitation for insurance.

By submitting this form you agree that a licensed insurance advisor may contact you regarding Medicare plan options by phone, text message, direct mail or email. You expressly consent to receive phone calls (including autodialed and/or pre-recorded calls) text messages, direct mail and email using automated technology at the phone number and address you provided, even if it is a wireless number, regardless of whether you are on any Federal or state DNC (“Do not call”) and/or DNE (“Do Not Email”) list or registry. In addition, you understand and acknowledge that data and message rates may apply. Furthermore, you acknowledge that you are over 18 years of age. By providing your email address, you agree to our privacy policy. Our licensed insurance advisors are independent contractors of Golden Outlook Insurance Services (CA license # 0E97515) who work with Medicare beneficiaries to explain Medicare Advantage, Medicare Supplement and Prescription Drug Plan options.

For additional information, you can also call 1-800-MEDICARE. Through 1-800-MEDICARE, you can hear a recording with answers to frequently asked questions, and can order publications 24 hours a day, 7 days a week. You can talk with a Customer Service Representative 24 hours a day, 7 days a week. If you are hearing impaired or speech impaired, call the TTY line toll-free at 1-877-486-2048.