We are excited to help you find the best plan for you.

We need to get a few things out of the way first. This process should only take you about 5 minutes.

Step 1

Contact Information

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Best day(s) of the week to contact you(Required)

Select all that apply

Best time of day to contact you(Required)

Step 2

Scope of Appointment

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary.

What plans would you like to discuss? (We can only discuss plans you are interested in learning more about – Check all that apply)(Required)

Medicare Advantage Plans (Part C) and Cost Plans

Stand-alone Medicare Prescription Drug Plan (Part D)

Medicare Supplement (Medigap) Plan

Dental-Vision-Hearing Products

Hospital Indemnity Products

Choose an Agent(Required)

Hidden

Agent Name

Hidden

Agent ID

By signing this form, you agree to meet with a Licensed Sales Representative to discuss the products checked on previous page. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential.

Signature for Beneficiary(Required)

Step 3

Privacy Notice Statement Pertaining to Personally Identifiable Information & Consent Waiver

Please read and sign our Privacy Policy

Privacy Notice Statement Pertaining to Personally
Identifiable Information & Consent Waiver

This Privacy Notice Statement (“Statement”) explains how contracted agents and employees of Medicare Masters, LLC and/or Anchor Health Insurance, LLC, (also referred to herein as “we” or “us”) may collect, use and disclose certain personally identifiable information (“PII”) in the course of assisting you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in qualified health plans (“QHPs”) through the Federally Facilitated Marketplace (“FFM” or “Marketplace”) or direct through the carrier, and/or applying for federal subsidies. PII includes any information that can be used to distinguish or trace your identity, either alone or in combination with other personal or identifying information that is linked or linkable to you. Examples of PII include your name, address, phone number, Social Security Number, date and place of birth, and mother’s maiden name.

This Statement describes, in particular:
1. The legal authority for our collection of PII;
2. The purpose of our collection of PII;
3. To whom and for what purposes PII may be disclosed;
4. Authorized uses and disclosures of any collected PII;
5. Whether our request to collect PII is voluntary or mandatory under applicable law; and
6. The effects of nondisclosure if you choose not to provide requested PII.

Please read this Statement carefully and contact us at admin@medicare-masters.com or 920-882-1307 if you have any questions or concerns.

We will take reasonable steps to ensure that any of your PII in our possession is complete, accurate, and up to date – to the extent necessary to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHPs through the Marketplace, and/or applying for federal subsidies – and has not been altered or destroyed in an unauthorized manner. We have implemented operational, administrative, technical, and physical safeguards and procedures, including privacy and security training programs for members of our workforce, to protect your PII and ensure its confidentiality, integrity, and availability, and prevent unauthorized or inappropriate access, use, or disclosure.

In accordance with our established privacy and security standards, which are publicly available upon request, you (or your duly authorized representative) have the right to a simple and timely means of accessing and obtaining your PII in a readable form and format, disputing the accuracy or integrity of your PII, and having erroneous information corrected, substituted or deleted. For instructions as to how to exercise your rights in this regard, please contact Nancy Rezmer at nancy@medicare-masters.com or call 920-882-1307. If the PII in question originated from another source, then you should contact the originating source for this purpose.

Legal Authority for Collection of PII
We have entered into an agreement with the Marketplace, under which we will comply
with the Marketplace’s privacy and security standards established by the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services. We may collect, use, or disclose your PII if and to the extent required under applicable law. In all other instances, we may collect, use, or disclose your PII, in accordance with this Statement, to the extent necessary to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHPs through the Marketplace, and/or applying for federal subsidies.

Purpose of Collection of PII
The purpose of our collection of PII is to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHPs through the Marketplace, and/or applying for federal subsidies.

To Whom and for What Purpose PII May Be Disclosed
We may disclose your PII to the Marketplace (or employees, agents or sub‐contractors thereof), certain federal or state agencies, a health insurance issuer offering a QHP that you have selected (or such issuer’s employees, agents, or subcontractors), or any individual who is duly and legally authorized to act on your behalf in connection with your PII. This includes any individuals acting under an appropriate power of attorney or appointment that complies with applicable state and federal law. Your PII may be disclosed to the extent necessary for us to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHPs through the Marketplace, and/or applying for federal subsidies.

Authorized Uses and Disclosures of Collected PII
We may use and disclose PII if and to the extent reasonably necessary to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHPs through the Marketplace, and/or applying for federal subsidies. We will obtain your informed consent, which you may revoke at any time, for any other uses or disclosures of PII.

Whether Request to Collect PII is Voluntary or Mandatory under Applicable Law
Our request to collect your PII, for purposes of assisting you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHPs through the Marketplace, and/or applying for federal subsidies, is voluntary.

Effects of Nondisclosure of PII
If you choose not to provide the requested PII to us, then we may be unable to assist you in comparing health insurance plans, obtaining determinations of eligibility for coverage, enrolling in QHPs through the Marketplace, and/or applying for federal subsidies.

FFM Person Search and MyMedicare.gov Access Consent Waiver
By signing this form you also authorize agents and employees of Anchor Health Insurance, LLC and Medicare Masters, LLC to access the Federally Facilitated Marketplace (FFM) and conduct searches for yourself and dependents and to work with them for purposes of applying for and enrolling in a Marketplace plan and to access your MyMedicare.gov account to access and update your prescription medications list for the purpose of enrolling in a Medicare Advantage or Medicare Prescription Drug Plan.

Disclaimer
Per Government regulations we are required to include the following disclaimer: “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.” Nonetheless, if a plan that we are not appointed with makes sense for you, we can still help you enroll in that plan.

Please contact us at admin@medicare-masters.com or 920-882-1307 if you have any questions or concerns regarding this Privacy Notice Statement, or our collection, use, and disclosure of PII in general.
I have reviewed this notice and have been given the opportunity to retain a copy thereof:

I have read and agree to the Privacy Policy above

Signature for Privacy Policy(Required)

Is there any other information you would like us to know?

Do NOT type any personally identifiable information like Social Security Number, Driver’s License, State ID, Medicare, Health plan or beneficiary numbers or information