Medicare Assistance Request Form

When you fill out this Medicare assistance request form, Alex will contact you and provide a personalized Medicare evaluation at the beginning of your Medicare initial enrollment period (3 Months before you turn 65)

First Name *

Last Name *

Phone *

Birthday *

Zip code

Email *

Do you have any urgent questions and want to talk about your Medicare situation sooner than the start of your initial enrollment period?

Yes

Do you take any medications on a regular basis?

Yes

Any comments in regards to your situation that Alex should be aware of: