Complete the intake form to see which plans are available in your county.

Earlene will reach out via text or email to schedule an appointment to discuss your plan options. (Please check your spam folder if you don't see an email.)

First Name *

Last Name *

Phone *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, and new product updates, among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt out.

Preferred time for follow-up call *

Who Referred You To Us?

Date of birth *

Sex *

Address *

Street Address *

City *

State *

Country

Postal Code *

County (reside) *

Is your mailing address the same as your street address? *

Mailing Address (If different)

Do you currently have both Part A and Part B of Medicare? *

Medicare Beneficiary Name (as it appears on card)

Medicare Number

Part A effective date

Part B effective date

Do you have state Medicaid (blue & white card or silver card) *

Medicaid #

What is your annual gross income? household income to be in 2026? *

Did you retire from the state? *

Did you keep your group medical benefits as a retiree from the state? *

Do you have any other medical coverage? *

Are you a veteran? *