Health Insurance Request

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Disclosure Statement

By submitting this form, you are consenting to receive phone calls from one of our licensed insurance agents who represent various health insurance companies such as Humana, Aetna, Assurant, and Coventry, amongst others. This is not an application for insurance and does not replace any coverage you may currently have.

By completing this form, you authorizing a licensed insurance agent to contact you to provide information regarding health insurance products, even if you are on the Do Not Call Registry.

The sales representative discussing the plan options with you is either employed by or contracted with an insurance carrier, and may be compensated based on your enrollment into a plan.

Note: Calls from AMAC appear on your phone as coming from the number: (631) 729-7319, or sometimes as potential SPAM (depending on your cell phone settings). Please keep this in mind if you made an inquiry or asked for a call from AMAC recently, as we will be trying to reach you.

AMAC, Inc. is neither endorsed by nor contracted with the US Government, or any federal/ state programs.

AMAC does not recommend health related products, services, or insurance plans. You are strongly encouraged to evaluate your needs.

By submitting this form, you acknowledge understanding and agreement to the above terms and conditions.

Cancer, Heart and Stroke

Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray copays/coinsurance. These plans are not affiliated or connected to Medicare.

The Association of Mature American Citizens (AMAC) is a licensed and certified representative of Medicare Advantage HMO, PPO and PFFS organizations and stand-alone prescription drug plans with a Medicare contract. Enrollment in any plan depends on contract renewal.

The plans we represent do not discriminate on the basis of race, color, national origin, age, disability, or sex. To learn more about a plan’s nondiscrimination policy, please click any of the Nondiscrimination links above in the Health plan disclaimers section.

This information is not a complete description of benefits. Call 1-800-334-9330 (TTY: 711) for more information.

Medicare beneficiaries may also enroll in the plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

For a complete list of available plans please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.

Every year, Medicare evaluates plans based on a 5-star rating system.

Out-of-network/non-contracted providers are under no obligation to treat Plan members, except in emergency situations. Please call the Plan’s customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Total annual cost is calculated by adding up the total annual cost of any monthly premiums, applicable plan deductible(s) and estimates for all co-pay and co-insurance amounts that will be due for the medications and health benefits used throughout the year. Costs for medications and health benefits vary across pharmacies and health systems, so the costs provided are only estimates. Actual costs could vary.

For plans with Part D Coverage: You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778 or consult www.socialsecurity.gov; or your Medicaid Office.

You must have both Part A and B to enroll in a Medicare Advantage plan. Members may enroll in the plan only during specific times of the year. Contact the plan for more information.

The purpose of this communication is the solicitation of insurance. Contact will be made by an insurance agent/producer or insurance company.

* By checking this box, I affirm that I am either the person named on this form, or have legal authority as authorized by a Court, such as having a Durable Medical Power of Attorney or Legal Guardianship to make health care decisions on behalf of the individual named on this form and am giving consent to have a licensed insurance agent contact me regarding the plans that I have selected above.

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