Personal Details

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. Please note that by signing this form you are agreeing to speak about Medicare Advantage, Medicare supplements and/or Medicare Prescription Drug plans.

By signing below and providing my e-mail address or telephone number, I agree to allow a licensed sales representative from TDR Financial Group to contact me regarding information related to Medicare health plans and health insurance plans, products, services and/or educational information related to health care. 

The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government.

Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.