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MEDICARE PART D

CLIENT REQUEST FORM

By submitting this form, I consent to Golden Years Design Benefits to contact me by email, telephone, or text message at the email or telephone number I provided for advertising or telemarketing purposes using an automatic telephone dialing system or artificial prerecorded voice. I understand that my consent to receive these calls, text messages, or emails is not a condition of purchase of any goods or services. We are not affiliated with or endorsed by the U.S. Government or the Federal Medicare Program. We are insurance brokers. This is a solicitation of insurance. .

My Medicare Helper

Video - Fill out Scope of Appointment Form

INSTRUCTIONS

Please create one (1) form for you and if you have a spouse, one for them.

WHEN FILLING OUT YOUR PRESCRIPTION DRUGS : Please add only Prescriptions you fill at the pharmacy. Please note if you must take the brand name instead of the generic please let us know. DO NOT INCLUDE OVER THE COUNTER ITEMS.

NEED FURTHER ASSISTANCE?

Please call 732-526-7659 or email [email protected]

By submitting this form, I consent to Golden Years Design Benefits to contact me by email, telephone, or text message at the email or telephone number I provided for advertising or telemarketing purposes using an automatic telephone dialing system or artificial prerecorded voice. I understand that my consent to receive these calls, text messages, or emails is not a condition of purchase of any goods or services. We are not affiliated with or endorsed by the U.S. Government or the Federal Medicare Program. We are insurance brokers. This is a solicitation of insurance. .

My Medicare Helper

Video - To Fill out Form

Video - Fill out Scope of Appointment Form

INSTRUCTIONS

Please create one (1) form for you and if you have a spouse, one for them.

WHEN FILLING OUT YOUR PRESCRIPTION DRUGS : Please add only Prescriptions you fill at the pharmacy. Please note if you must take the brand name instead of the generic please let us know. DO NOT INCLUDE OVER THE COUNTER ITEMS.

If Part D Drug plan is not available on the dropdown, kindly indicate the right plan on the next text box field.

Kindly fill out medicare.gov Username and Password if you have any. If not, just leave it blank.

NEED FURTHER ASSISTANCE?

Please call 732-526-7659 or email [email protected]

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

Your Licensed Medicare Insurance Broker:

55 Schanck Road Suite A-14

Freehold, NJ 07728

732-526-7659

We are not connected with or endorsed by the United States Government, Social Security, CMS, Health Insurance Marketplace, State Government, Local Government, SHIP, PACE, Veterans Administration, Medicaid, or Medicare. This is a solicitation for insurance and you may be contacted by a licensed insurance agent from your State of legal residence. By pressing submitting your RSVP (1) I consent to receive emails, telephone calls, ai voice calls, text messages, artificial or pre-recorded messages from Golden Years Design Benefits , regarding their products and services at the email address and telephone number provided, including my wireless phone number (if provided), utilizing an automated telephone dialing system and I understand that I am not required to grant this consent as a condition of purchasing and property, goods or services from the foregoing companies (2) I agree to this websites Privacy Policy and Terms of Use. This consent is provided even if the phone number appears on any local, state, or federal do not call list. We do not offer every plan 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 24 hours a day/7 days a week to get information on all your options. We are an independent insurance brokerage agency working with many private insurance companies that provide supplemental coverage to the Medicare program.

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