Permission to Contact

By signing this form, I give my consent to Harold Sanchez to contact me up to 12 months after the signature date by phone call, text message, email, postal mail or any other marketing communication to provide information about the products and services I selected. Your consent is voluntary and you may contact us to change your preferences at any time. Changing your preferences will not affect your eligibility for benefits and enrollment, payment for coverage of services, or ability to get treatment. All information provided on this form is confidential and should be completed by each person eligible for Medicare or his/her authorized representative. Please note the agent who will discuss the products is either employed or contracted by a Medicare insurance plan. The agent does not work directly with the Federal government. You are not obligated to enroll in any product. Signing this form does NOT obligate you to enroll in a plan. Your current enrollment will not be affected. You will not be auto-enrolled in a Medicare plan. You acknowledge the following products will be discussed based upon your state and county of residence: *Medicare Advantage plans (MAPD)Medicare Supplement plans (Medigap)Stand-alone Prescription Drug plans (PDP)Ancillary Products (Dental, Vision, Hearing, Accident, Critical Illness)Hospital Indemnity Products

To be completed by Beneficiary and/or Authorized Representative

Beneficiary First Name *

Beneficiary Last Name *

Beneficiary Address *

Beneficiary Phone Number *

Beneficiary Email *

Authorized Representative

Your Relationship to Beneficiary

Signature of Beneficiary or Authorized Representative *CMS requires a licensed agent to document the beneficiary or authorized representative consent before the member can be contacted by an agent.

Signature Date *I give consent to be contacted up to 12 months past the signature date.

To be completed by Agent

Agent Name *

Agent Phone *

Initial Method of Contact *

Plan(s) the agent represented during the meeting *

Date of Agent Signature *

Agent Signature *The full name entered by the licensed agent is the equivalent to a handwritten signature

Permission to Contact

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(470) 632-5770