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Disclaimer:

Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan. By entering your information below and clicking Submit, you are giving permission to have a licensed sales agent contact you by email, telephone or cell phone to provide additional information about products and services. Your consent is voluntary and allows us to contact you via email, text messaging, artificial or prerecorded voice messages, or automatic dialing for marketing purposes. You may contact us to change your preferences at any time. Data use charges and rates from your cellular carrier may apply. By signing this form, you agree to be contacted by a licensed sales agent to discuss the types of products you selected above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any 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.

Medicare Required Disclaimers

• 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 your options.
• Medicare & Me is a licensed and certified representative of a Medicare Advantage organization with a Medicare contract. Enrollment in any plan depends on contract renewal. Kim-Say Dinh is a licensed and certified representative of Medicare Advantage [HMO, HMO SNP, PPO, PPO SNP and PFFS] organizations [and stand-alone PDP prescription drug plans] that have a Medicare contract. Enrollment in any plan depends on contract renewal.
• By dialing the number you will contact a “licensed sales agent” or “licensed insurance agent”.
• To send a complaint to Medicare, call 1-800-MEDICARE (TTY users should call 1- 877-486-2048), 24 hours a day/7 days a week). If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.
• Every year, Medicare evaluates plans based on a 5-star rating system. The Star Ratings apply to contract year 2023 .