Disclosures

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DISCLOSURE

Me and Medicare

Call Recording Consent & Verbal Authorization

YES – I consent to this call being recorded for quality, training, and compliance purposes. I authorize the representative to document my verbal responses on this form with my permission.

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NO OBLIGATION TO ENROLL

Talking with me does not obligate you to enroll in a Medicare plan. You should enroll only when you are ready and have decided that a plan is appropriate for your needs.

You will never be required to enroll simply because you requested information or spoke with me.

ABOUT ME AND MEDICARE

Me & Medicare is an independent insurance agency. We are not affiliated with, endorsed by, or employed by Medicare, Medicaid, CMS, or the federal government.

Do you have someone who helps you with your Medicare or medical decisions?*

Yes

Support Contact First Name

Support Contact Last Name

Support Contact Phone Number

Relationship to Client

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Medicare Plan Availability Disclosure (TPMO)

We do not offer every plan available in your area. Currently we represent ( ___ ) organizations which offer ( ___ ) products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Organzation #

Product #

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SCOPE OF APPOINTMENT (SOA) – What Would You Like to Discuss?*

Medicare Advantage (Part C)

Medicare Supplement (Medigap)

Prescription Drug Plans (Part D)

Hospital Indemnity - Help with Copay & deductibles

Dental / Vision/ Hearing

A Scope of Appointment (SOA)

lets us know which types of Medicare coverage you would like to review during our appointment. Please select all that apply.

We will only discuss the Medicare product types you authorize below. Selecting an option does not obligate you to enroll in a plan or change your current coverage.

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PERMISSION TO CONTACT Requested Medicare Assistance *

YES, I authorize Me & Medicare LLC to contact me at the number provided, including for Medicare-related updates and marketing communications described below.

NO , I do not authorize these additional communications.

Communication Methods & Consent

Communications may include live calls, texts, automated dialing, prerecorded messages, and AI-generated voice messages, including marketing. I may withdraw my consent at any time. My consent to automated marketing is not required to purchase services.

What type of health insurance coverage do you currently have?

Original Medicare (Part A & Part B)

Medicare Advantage Plan (Part C)

Medicaid

Medicare Supplement (Medigap)

No Current Coverage

NOT Sure

Which of the following Medicare plan benefits are most important to you?

Part B premium reduction (Giveback)

Keeping my current doctors and specialists

Dental coverage

Vision coverage (eyeglasses and exams)

Hearing coverage (hearing aids)

Prescription drug coverage

Over-the-counter (OTC) allowance

Lower copays and out-of-pocket costs

Hospital coverage

Transportation benefits

Fitness benefits

Additional Notes

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Agent Information:

Name: Kent Farley

NPN: 5776547

Business Phone: (971) 366 - 2500

Email: Kent@meandmedicare.com

Website: www.meandmedicare.com

Assistant Information:

Stephanie Farley

NPN: 21306024

Email: Steph@meandmedicare.com

About Us: www.meandmedicare.com/about-us

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Client's first name*

Client's last name*

Client's Phone

Client's Email

Person/Agent/Representative Completing This Form

Business Info

Me and Medicare LLC

South Dakota
(971) 366-2500
Hello@MeandMedicare.com

Support@MeandMedicare.com

Disclaimer: The information provided on this website is for general educational purposes about Medicare Advantage (Part C), Medicare Part D, and related services. Costs, copays, coinsurance, benefits, and coverage rules vary by plan, provider network, and service area. You must continue to pay your Medicare Part B premium.

Me and Medicare LLC is a privately owned and operated insurance agency and is not affiliated with or endorsed by the U.S. government or the federal Medicare program.

We do not offer every plan available in your area: 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 to get information on all of your options.

DISCLOSURE

Me and Medicare

Disclosures

Agent Information:

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