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Fill Out the Form Below

We require your consent before contacting you to go over your Medicare plan alternatives, given Medicare regulations. By filling out the form below , you consent to a licensed insurance agent from Health Max Insurance, to contact you by mail, phone, sms or email to discuss particular products for marketing purposes regarding Medicare Advantage and Medicare Supplement. The person who will talk to you about your plan alternatives is contracted by a Medicare health plan that is not a Federally-sponsored program, and they might receive payment based on your participation in a plan. Your current enrollment in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan will not be impacted by signing this form, nor will it enroll you in one.

The consumer agrees to receive telephonic sales and marketing calls and text messages using an automated system for the selection or dialing of telephone numbers, including automated voice calls, AI-generated voice calls, prerecorded messages played when a connection is made, or prerecorded voicemail messages. These calls and messages are for marketing purposes, and cellular charges may apply. Providing this permission does not impact the consumer’s eligibility to enroll. The consumer may change their permission preferences at any time by contacting Health Max Insurance. The consumer provides this consent even if their telephone number is listed on a Do Not Call registry.

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