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334 East Lake Road Suite 364 Palm Harbor, FL 34685

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Medicare rules require that we need your permission to contact you to discuss your Medicare plan options. By accepting this form, you are agreeing to a sales telephone call or an email from a licensed sales agent to discuss the specific types of products above. The person who will be discussing plan options with you is with or contracted by a Medicare health plan or prescription drug plan that is not the Federal Government. They may be compensated based on your enrollment in a plan. Signing this form does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan. By providing your e-mail address or telephone number, you agree to allow a licensed sales agent to contact you regarding information related to Medicare health plans, health insurance plans, products, services and/or educational information related to health care.

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