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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)

Not sure

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.

Contact Us

918-819-4273

Tulsa, OK

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