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MEDICARE REVIEW FORM

Annual Enrollment 10/15 through 12/7

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ONLY COMPLETE IF YOU ARE CONSIDERING A PLAN CHANGE

Are you a current Roberson Tierney client?
Who do you work with?
Were you referred to us?
Current Plan
Do you get extra help? QMB Connect Card/ Low Income Subsidy/Huksky?
Please check off the product(s) you agree to discuss in your appointment
Please check off any additional concerns you may have.

Signing this form does not obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

Thanks for your submission.

We will be in touch with the next 24 hours.

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