Current Martin's Point Members

Martin's Point Value Plus Response Form

Name

First Name

Last Name

Message

Optional

Please choose one:

My PCP is:

My Eye Doctor is:

My Dentist is:

My Specialists are:

My Pharmacy is:

My Prescriptions are (taken from the bottle):

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.

Martin's Point Value Plus Response form - Andro, Kenn County

Name

First Name

Last Name

Message

Please Choose One:

My PCP is:

My Eye Doctor is:

My Specialists are:

My Prescriptions are (taken from the bottle):

My Pharmacy is:

Kindly complete the required Scope of Appointment form below:

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:

Today's Date

YYYY

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

Martin's Point Value plus response form - saga County

Name

First Name

Last Name

Message

Please Choose One:

My PCP is:

My Eye Doctor is:

My Dentist is:

My Specialists are:

My Pharmacy is:

My Prescriptions are (taken from the bottle):

Martin's Point Prime and Value Plus Repsonse form - aroos, frank, hanc, knox, linc, oxf, penob, pisc, somer, waldo, wash counties

Name

First Name

Last Name

Message

Please choose one:

My PCP is:

My Eye Doctor is:

My Specialist are:

My Dentist is:

My Pharmacy is:

My Prescriptions are (taken from the bottle):

New Page Form

Name

First Name

Last Name

Message

Optional

Please choose one:

My PCP is:

My Eye Doctor is:

My Dentist is:

My Pharmacy is:

My Prescriptions are (taken from the bottle):

Martin's Point Prime Response Form - Cumb, York

Name

First Name

Last Name

Message

Please Choose One

My PCP is:

My Eye Doctor is:

My Dentist is:

My Pharmacy is:

My Prescriptions are (taken from the bottle):