FORM NAME: Contact us for help with your Medicare options Edit d8d8448de4acf39f0d205239932f69cebadc8ef71bc2b9c3ac1d78a0cb314053

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Digital Signature for Scope of Appointment By signing above and clicking Submit, you are giving permission to have a licensed sales agent contact you by email or phone to discuss the types of products you selected above. Your consent is voluntary. Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. Please note, the person who will discuss the products is contracted by Medicare plans. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Agents are required to document the scope of a marketing appointment prior to any 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.

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