Consent Form CompanyThis field is for validation purposes and should be left unchanged.Name(Required) First Name Last Name Phone(Required)Email(Required) Date of birth(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Job Title/DepartmentEmployee IDPlan Location Information City State / Province / Region ZIP / Postal Code Employee Acknowledgments(Required)By signing below, I acknowledge and agree to the following: 1. Voluntary Participation I understand that I am not required to enroll in Medicare and may remain on my employer’s group health plan if I choose. 2. No Employer Pressure I confirm that my employer has not pressured, required, or forced me to consider or enroll in Medicare coverage. 3. Coverage Options Explained I have received information explaining: o My employer-sponsored health plan o Medicare Parts A and B o Medicare Advantage and Medigap options o Prescription drug coverage (Part D) o How Medicare coordinates with employer coverage 4. Right to Remain on Group Plan I understand that I have the right to continue my employer-sponsored coverage while actively employed, subject to plan rules. 5. Cost and Coverage Comparison I have been provided with a written comparison of estimated costs and benefits between my employer plan and Medicare options. 6. Authorization to Review Benefits I authorize the consulting/enrollment company to review my benefit information solely for the purpose of providing Medicare guidance and enrollment assistance. 7. Disclosure of HSA Impact I understand that enrolling in any part of Medicare may affect my ability to contribute to a Health Savings Account (HSA). 8. No Guarantee of Savings I understand that switching to Medicare may or may not result in cost savings and that coverage features may differ from my employer plan. 9. Privacy and Confidentiality I authorize the secure use and storage of my personal and health information in accordance with applicable privacy laws. 10. Opportunity to Ask Questions I confirm that I have had sufficient opportunity to ask questions and receive clear answers. I confirm that I have read and understood the Employee Acknowledgments outlined above.Employee Election (Please Select One)(Required) I choose to remain on my employer’s group health plan at this time. I choose to transition to Medicare coverage. I choose to delay my decision and request additional information. Authorization for Enrollment Assistance (If Applicable)If I elect to transition to Medicare, I authorize the consultant/agent to assist me with: Medicare Part A enrollment Medicare Part B enrollment Medicare Advantage enrollment Medigap enrollment Part D enrollment DisclaimerI understand that the consulting/enrollment company does not provide legal or medical advice and that final healthcare decisions remain my responsibility. I am encouraged to consult with my healthcare providers and personal advisors before making coverage changes.Signature(Required)Today's Date(Required) MM slash DD slash YYYY
