Medicare Discussion Authorization

Scope of Appointment

Already ready to discuss specific Medicare plans? Complete this authorization form to schedule a plan-specific conversation with our licensed agent.

This is NOT an enrollment form.

This form only authorizes a discussion about the Medicare plan types you select below. You are under no obligation to enroll in any plan.

Select Plan Types to Discuss

Medicare Advantage (Part C)Prescription Drug Plans (Part D)Medicare Supplement (Medigap)Dual Eligible Special Needs Plan (DSNP)

Your Information

Preferred Meeting Date & Time

Date

Time

Electronic Signature

By typing your full name below, you authorize Insuras Health Benefits to discuss the selected Medicare plan types with you. This is not an enrollment authorization.

By submitting this form, you confirm that you are the Medicare beneficiary (or authorized representative) and you authorize Insuras Health Benefits to contact you to discuss the selected plan types. This authorization is valid for the duration of the appointment and does not obligate you to enroll in any plan.

A licensed Medicare agent will review your needs before any plan recommendation or enrollment. Calls may be recorded for quality assurance.

Insuras Health Benefits is not affiliated with or endorsed by Medicare or any government agency.

Not ready for a plan discussion? Contact us for general questions instead.