Permission to Contact

The Centers for Medicare & Medicaid Services (CMS) requires that before I contact you about Medicare health or drug plans by phone, text, or email, I first get your explicit written permission. This is called a Permission to Contact (PTC). It ensures I never reach out to you unless you’ve asked me to.

Your permission is voluntary. You are not required to provide it, and refusing or revoking it will not affect your eligibility for, or enrollment in, any Medicare plan. If you give me permission, it lasts for 12 months, and I will only contact you using the methods you select below to discuss the products you choose.

You may revoke this permission at any time by calling me, emailing me, or clicking the opt-out link in any message I send you. We will honor your request promptly and stop all future contact.

This is a solicitation for insurance. This is not connected with or endorsed by the U.S. government or the federal Medicare program.

I do not offer every plan available in your area. Currently I represent 6 insurance carriers, and the number of products available varies by county. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Assistance Program (SHIP) to get information on all of your options.

This is not connected with or endorsed by the U.S. government or the federal Medicare program.

First Name *

What is your first name as it appears on your Medicare card (if applicable)?

Last Name *

What is your last name as it appears on your Medicare card (if applicable)?

Email *

What is the best email that you regularly check?

Phone Number *

Preferred Contact Method *

Phone

Text

How would you like to be contacted?

Best Time to Contact *

What is typically the best time to contact you?

Products to Discuss (select all that apply) *

Medicare Advantage (MA)

Medicare Advantage with RX (MAPD)

Part D Prescription Drug Plan (PDP)

Medicare Supplement (Medigap)

Consent to Contact *

I authorize Medicare Precision to contact me via the methods selected above. This permission is voluntary, not a condition of enrollment, and may be withdrawn at any time. I understand I can revoke this permission by calling, emailing, or using the opt-out link in any message I receive. Medicare Precision will honor my request promptly.

By typing my full legal name and signing below, I provide my electronic signature under the U.S. E-Sign Act. I acknowledge this Permission to Contact will be recorded with my submission date and time.

Type your full legal name *

Sign your full legal name *

Clear