Connect One Health Medicare Survey Connect One Health will use your responses to this Survey to provide you with a quote for a Medicare Advantage Plan or a Medicare Supplement Plan. It should only take you a few minutes to complete and you do not have to provide any confidential or Protected Health Information.Please enter your first and last name.(Required) Please enter your zip code.(Required) ZIP / Postal Code Best Contact Number(Required)Please enter the telephone number at which you would like to be contacted by a Connect One Health licensed agent.Is the telephone number you provided for a cell phone?(Required) Yes No Please enter your email address. (Optional) Are you currently enrolled in Medicare Parts A and B?(Required) Yes No We’re Sorry! If you are not enrolled in Medicare Parts A and B, you are not currently eligible to enroll in a Medicare Advantage Plan or a Medicare Supplement Plan. However, if you are age 65 or you are within three months of your 65th birthday, we can help! Please Click Here and read How do I enroll in Medicare?, which will show you how to enroll in Medicare Parts A and B.Are you receiving financial assistance such as State Medicaid, prescription drug assistance, Food Stamps or Medicare Part B assistance?(Required) Yes No Do you have a Power of Attorney that appoints someone to help you make medical decisions?(Required) Yes No Do you have insurance known as Tricare for Life?(Required) Yes No Do you currently have Medicare Part C, otherwise known as a Medicare Advantage Plan?(Required) Yes No Do you currently have a Medicare Supplement or Medigap Plan?(Required) Yes No I am interested in receiving a quote for a (please check all that apply) Medicare Advantage Plan Medicare Supplement Plan Both types of Plans For your current Part C / Medicare Advantage Plan, please provide the following information:What is the name of the insurance carrier who provides your Plan?(Required) What is your monthly premium that you pay for your Plan?(Required)Is your Plan a Health Maintenance Organization (“HMO”) or a Preferred Provider Organization (“PPO”)?(Required) HMO PPO I don’t know What is your co-pay cost to see a Specialist under your current Plan?(Required) I don’t know Other I am interested in receiving a quote for a (please check all that apply)(Required) Medicare Advantage Plan Medicare Supplement Plan Both types of Plans For your Medicare Supplement Plan, please provide the following information:Please enter the name of the insurance carrier who provides your plan.(Required) Please enter the amount of monthly premium you pay for your plan.(Required)I am interested in receiving a quote for a (please check all that apply)(Required) Medicare Advantage Plan Medicare Supplement / Medigap Plan Both types of Plans Consent(Required)I verify that the contact information entered in connection with this Survey is correct and is my personal information, and that I am at least 18 years of age. By submitting this Survey, I agree that a licensed sales representative may contact me at the telephone number provided by me, about Medicare Advantage, Prescription Drug, and/or Medicare Supplement Insurance plans. I agree.NameThis field is for validation purposes and should be left unchanged. Δ
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