Medicare Consent and Acknowledgement

Licensed Health Insurance Agent Notice

I understand I am consenting to receive assistance from a licensed health insurance agent assigned to my case. The assigned agent will be properly licensed/appointed and identified to me prior to any enrollment activity.

I confirm that all personal and Medicare eligibility information I provide is accurate to the best of my knowledge. This information will be used to evaluate and discuss Medicare plan options consistent with applicable CMS marketing guidelines.

Agent of Record (AOR) Consent

I appoint the assigned licensed health insurance agent as my authorized assigned health insurance agent for Medicare insurance matters, including plan discussions, enrollment assistance, and policy changes. I may revoke or modify this consent at any time.

Scope of Appointment (SOA)

I consent to discuss the following Medicare-related products:

• Medicare Advantage (Part C)

• Medicare Prescription Drug Plans (Part D)

• Medicare Supplement Insurance (Medigap)

This SOA is valid for up to 12 months unless I revoke or modify it sooner. No other products will be discussed unless a new SOA is completed.

HIPAA / HRA Authorization

I authorize collection and use of my health information for plan evaluation and enrollment support, including health risk assessment (HRA), conditions, medications, and preferred doctors. My information will be handled confidentially and in accordance with applicable privacy and data protection laws. I may revoke this authorization at any time, except to the extent actions have already been taken in reliance on it.

Medicare Claim ID Number / Eligibility Lookup Authorization

If I do not provide my Medicare Claim ID Number, I authorize the assigned agent or their service providers to securely verify or look up my Medicare Claim ID Number and Medicare eligibility using identifiers such as my name, date of birth, and my Social Security Number. Any such lookup will be used solely to evaluate my plan options and/or complete enrollment.

Marketing & Communication Standards

All marketing communications will follow CMS marketing rules, including prohibitions on misleading statements and door-to-door solicitation. I understand that plan details, benefits, and costs vary by location and eligibility and will be explained to me before any enrollment.

Third-Party Marketing Organization (TPMO) Disclaimer

We do not offer every plan available in your area. Any information provided is limited to the plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. Plan availability varies by location and eligibility. The agent may be compensated by insurance companies for enrollments; this does not affect your premiums or benefits.

TCPA Consent to Contact

By submitting this form, I agree that a licensed health insurance agent may contact me by phone, text (SMS), or email, including via automated technology, at the contact information I provide—even if my number is on a state or federal Do Not Call list. Message and data rates may apply. I can opt out at any time.

No Guarantees & Enrollment Implications

I understand there are no guarantees of eligibility or enrollment outcomes. Any changes to my current coverage—including termination or modification—will be explained before enrollment, and I will be asked to confirm my understanding.

Accessibility & Equity

Interpreter services and alternate formats are available upon request to support equitable and accessible communications.

Electronic Signature (ESIGN)

By signing or submitting electronically, I agree to the terms above and consent to conduct business electronically. I understand that my consent, signatures, and acknowledgements will be captured with date/time and may include device/IP information.

Disclaimer

Built to align with CMS marketing and data standards. Not affiliated with, endorsed by, or acting on behalf of the U.S. government, the Centers for Medicare & Medicaid Services (CMS), or any Medicare carrier.