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Intake Form

Are you currently enrolled in Medicare?

Yes

No

Which Medicare plan are you currently enrolled in?

Original Medicare (Part A & Part B)

Medicare Advantage (Part C)

Prescription Drug Plan (Part D)

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What type of assistance are you seeking? (Check all that apply)

Medicare enrollment assistance

Understanding Medicare benefits

Comparing plans

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I consent to be contacted regarding my Medicare inquiries, including but not limited to: Information about Medicare plans and benefits, Assistance with enrollment and eligibility, Follow-up regarding my inquiries or requests for information, Updates on Medicare-related services or changes.

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We do not offer every plan available in your area. Currently, we represent 8 organizations which offer 78 products in your area. Please contact, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.

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918-819-4273

Tulsa, OK

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