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We have a couple of optional questions to help provide you with plan options. Upon completion of this short form, I’ll contact you to discuss plan options in your area and answer any questions!

By providing the information in this form, you are granting permission for a licensed insurance agent to contact you via phone, text, or email regarding your Medicare options including Medicare Supplement, Medicare Advantage, and Prescription Drug Plans. Providing permission does not impact eligibility to enroll or the provision of services.

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Affordable Health and Life Agency is a licensed health insurance agency and is not affiliated or endorsed by the government or Federal Medicare program.

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We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please visit Medicare.gov or call 1-800-MEDICARE to get information on all of your options.

Affordable Health and Life Agency represents Medicare Advantage (HMO, PPO, PFFS) organizations and standalone PDP Prescription Drug plans that have a Medicare contract. Enrollment depends on the plan’s contract renewal.

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What's your phone number?

We promise to only call you if you indicate that you want us to by providing your phone number below.

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Let's take a look at your current prescriptions.

Please have your prescription bottles ready so we know exactly which medications you take. (Spelling, dosage and frequency are important!)

Please enter your current prescription medications:

Do not include over-the-counter medications, vitamins, supplements, or specialty drugs administered at your doctor's office or facility.

Do you have more than 5 prescriptions?

Tell us about your Doctors and Hospitals.

To provide plan options in your area, We’ll need some info on your doctors and preferred hospital(s) to verify their network status.

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Who are your physicians?

Primary Care Physician

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Scope of Sales Appointment Confirmation Form

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The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

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Please initial on the type of product(s) you want the agent to discuss with you.

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CMS requires your initials before we can provide you plan options in your area. Click "Next" to get started on this final part.


Stand-alone Medicare Prescription Drug Plans

(Part D)

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Medicare Prescription Drug Plan (PDP) - A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.


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Medicare Advantage Plans (Part C) and Cost Plans

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Medicare Health Maintenance Organization (HMO)- A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan's network (except in emergencies).Text

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Once submitted, please allow up to 3 business days for your agent to review the information. If support was requested, they will be in touch with you to gather the additional details. We look forward to supporting you in your insurance needs and will be in touch with you soon!

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States Licensed in: Arkansas, Arizona, Colorado, Missouri, Oklahoma, Tennessee, Texas

National Producer Number for Affordable Health and Life Agency: 9094353

Affordable Health and Life Agency is NOT AFFILIATED with any Government Agency.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-Medicare, or your local state health insurance program, (SHIP) to get more information on your options.

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