Medicare AEP - Request a Review — Coveside: Healthcare Coverage Options

I am Requesting a Medicare Annual Election Period Review of Coverage

Please choose one:

I am a current client of Coveside

I am new to Coveside

My current coverage is (Please complete if you are NEW to Coveside):

My County is (Please complete if you are NEW to Coveside):

Name

First Name

Last Name

Address

Message

Phone

(###)

###

####

Kindly complete the required Scope of Appointment form below:

I understand that I am requesting a meeting with an independent insurance agent at Coveside Healthcare Coverage Options who has a contract with Aetna, Anthem, Humana, Martin’s Point Generations Advantage, and UnitedHealthcare, and to offer their Medicare plans.

I understand that the representative will be discussing Standalone Medicare Prescription Drug Plans, Medicare Advantage plans, and other Medicare-related products, such as Medicare Supplement plans or Dental, Hearing, Vision.

I understand that the person who will be discussing these plans are contracted by private companies who have a Medicare contract to offer Medicare Advantage, Medicare Prescription Drug, and Medicare Supplement plans.

I understand that if I agree to this appointment, there is no obligation to enroll, current or future Medicare enrollment status will not be impacted, nor will it automatically enroll me in a Medicare Advantage Plan, Stand-alone Prescription Drug Plan, or other Medicare-related product.

I understand I am not required to provide any health-related information to our insurance agents unless it will be used to determine enrollment eligibility.

By Typing My Name Below I am Acknowledging Acceptance of the Above:

Date

YYYY

I have read the Medicare required statement: “We do not offer every plan available in your area. Currently, we represent 5 organizations that offer 46 products in our area. Please contact Medicare.gov or 1-800-MEDICARE or your local State Health Insurance Program to get information on all of your options.”

I understand Medicare requires phone and zoom conversations to be recorded and recordings are stored securely.