1. Adaptive Form Title
3. First Name
4. Last Name
5. ZIP Code
6. County
7. Section
8. Would you like to have an agent visit you in person?
9. Comments
10. CAPTCHA
12. Submit Request
13. By sharing your phone number, you’re giving permission for a licensed Select Health Medicare agent to contact you by phone to provide information about Medicare Advantage plans. Your consent is voluntary and allows Select Health to contact you via text messaging or email for marketing purposes. You may unsubscribe from emails at any time, and doing so will not affect your eligibility for Select Health benefits and enrollment, coverage, or ability to get treatment. Data use charges and rates from your cellular carrier may apply.

• Section

Medicare Information Request

Submit this form and an agent from our Medicare Team will reach out to you with further information.

* Indicates a Required Field

First Name

Last Name

ZIP Code

County

This ZIP code has numberOfCounties. Select your county to proceed.

Plan Information Type

This county offers multiple plan types. Which would you like to receive information about?

Select Health does not currently offer Medicare Advantage Plans in your area. Please visit Medicare.gov for more information.

This county offers multiple plan types. Which would you like to receive information about?

How do you wish to be contacted about Medicare Advantage Plans? (Please select one or more)

Email

Email Address

Phone

Phone Number

Best time to call?

Morning

Afternoon

Evening

Mail

Street Address

Address Line 2

City

State

Required

Would you like to have an agent visit you in person?

Yes, I would like to set up a meeting.

No, just send me the information.

Comments

Request not successful

It looks like this name and email have already been used to submit the form. If you believe this is a mistake, please reach out to the Medicare Team for assistance.  855-442-9900 (toll-free)

Submit Request

By sharing your phone number, you’re giving permission for a licensed Select Health Medicare agent to contact you by phone to provide information about Medicare Advantage plans. Your consent is voluntary and allows Select Health to contact you via text messaging or email for marketing purposes. You may unsubscribe from emails at any time, and doing so will not affect your eligibility for Select Health benefits and enrollment, coverage, or ability to get treatment. Data use charges and rates from your cellular carrier may apply.

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