MEDICARE CONSENT: If, at any time, I choose to cancel this authorization, I understand that I must do so in writing by sending my name, address, date of birth and member ID number to Jean Rollin Deshommes ASIREM’ an Expert Media Group LLC and Expert Financial Group LLC Brand, 1821 S. Dixie Highway, Pompano Beach, FL 33060 Unless cancelled as noted above in writing, this consent is valid until I cancel my CONSENT. For customers in the following states: FL, IN, IA, CA, CT, GA, IL, MA, MD, MT, NC, NJ, NV, OH, OR and VA, consents will expire in compliance with applicable state laws. I understand it's Jean Rollin Deshommes ASIREM’ an Expert Media Group LLC and Expert Financial Group LLC brand policy not to disclose my personal information to third parties-except as permitted under the federal privacy laws. Jean Rollin Deshommes ASIREM’ an Expert Media Group LLC and Expert Financial Group LLC Brand is required to let me know that should my personal information be disclosed to third parties;; the information can be redisclosed and may not be protected by privacy laws. I understand that Jean Rollin Deshommes ASIREM’ an Expert Media Group LLC and Expert Financial Group LLC Brand may receive direct and indirect compensation from third parties as a result of the sale of certain products. I authorize Jean Rollin Deshommes ASIREM’ and Expert Media Group LLC and Expert Financial Group LLC Brand affiliates to send the above-requested information on the health-and non-health-related products and services using my name and address, and (if provided), my gender, date of birth, phone number and email address.

First Name *

Middle name *

Last Name *

Phone *

Address

Street Address

City

State

Country

Postal Code

Email *

(By providing your email/phone number, you consent to receiving information via email, phone or text.)

(DOB) *

Member ID

Please Indicate Your Basic Understanding of Medicare

I could use a refresher on Medicare basis____ I Have solid Understanding of how Medicare works ___

Radio

Are You Enrolled in Medicare? *

Yes

No

Do You Take Prescription Medications Currently? *

Yes

No

Is Mail-order Pharmacy Option Important to You? *

Yes

No

Do You Have a Primary Care Doctor? *

Yes

No

Infos of Primary Care Doctor

PCP First Name

PCP Last Name

PCP Address *

City
Town

Do You See Other Specialist Doctors on a Regular Basis?

Yes

No

Specialist 1

First Name
Last Name
Specialty
City
Town

Specialist 2

First Name
Last Name
Specialty
City
Town

Specialist 3

First Name
Last Name
Specialty
City
Town

Specialist 4

First Name
Last Name
Specialty
City
Town

Specialist 5

First Name
Last Name
Specialty
City
Town

Specialist 6

First Name
Last Name
Specialty
City
Town

Specialist 7

First Name
Last Name
Specialty
City
Town

Specialist 8

First Name
Last Name
Specialty
City
Town

Specialist 9

First Name
Last Name
Specialty
City
Town

Specialist 10

First Name
Last Name
Specialty
City
Town

Do You Have a Dentist?

Yes

No

Dentist 1

First Name
Last Name
City
Town

Dentist 2

First Name
Last Name
City
Town

Notes or Important Additional Providers (hospitals, rehab facilities, etc.)

What was your Modified Adjusted Gross Income from 2 years ago?

Yes

No

Do you file your taxes individually or jointly with a spouse?

Individual Tax Return
Joint Tax Return
Married Filing Individually

Will Your Spouse Need Medicare Coverage?

Yes

No

First Name of Spouse

Last Name of Spouse

DOB of Spouse

Is Your Spouse Covered Under Your Health Insurance (or vice versa)? *

Yes

No

Is Your Spouse Covered Under Your Health Insurance (or vice versa)?

Yes

No

Does Your Spouse Take Prescription Medications? *

Yes

No

Spouse's Preferred Retail Pharmacy

Preferred Retail Pharmacy
City Town

Is a Mail-order Pharmacy Important to Your Spouse?

Yes

No

Does Your Spouse have Primary Care Doctor?

Yes

No

Does Your Spouse See Specialist Doctors on a Regular Basis?

Yes

No

Does Your Spouse Have a Dentist?

Yes

No

Spouse's Additional Care Notes & Provider Details (hospitals, rehab facilities, etc.):

What’s your top priority?

A plan with low or no medical co-pays

A plan with low monthly premiums

What means the most to you?

A plan with nationwide in-network coverage

A plan with low monthly premiums

What’s most significant for you in this decision? *

A plan that includes dental, vision and health club benefits

A plan with low or no medical co-pays

Have you decided which type of Medicare plan you’re interested in? *

Signed by Member or Legal Representative

Clear

Completion Date

I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws of the state where the individual resides) on this form means that I have read and understand the contents of this form. If signed by an authorized representative (as described above), the signature certifies that: 1) this person is authorized under state law to complete this form and 2) documentation of this authority is available upon request. If you are the authorized legal representative, you MUST sign above and provide the following information

Your Last Name

Your First Name

Address Line 1

Address Line 2

Your Zip code

City / state

Office Use only Agent Name: Jean Rollin Deshommes NPN:18482858 Agent SAN:_______________________ 1821 S. Dixie Highway, Pompano Beach, FL 33060 Tel: 1-833-747-0398 Fax:561-757-7027 *Required + Expires in 12 months: FL, IN, IA, CA, CT, GA, IL, MA, MD, MT, NC, NJ, NV, OH, OR Expires in 24 months: MT and VA Disclaimer “We’re Not connected with or endorsed by the U.S. government or the federal Medicare program. Calling this number will connect you with a licensed insurance agent.”

NOTE: Emergency room coverage is available worldwide on all plans.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

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