Permission to Contact About Medicare

Use this form to give TCG Insurance Solutions permission to contact you about Medicare-related questions or coverage options you request information about.

What this form does

Medicare rules limit unsolicited contact. This form documents that you are requesting contact from TCG Insurance Solutions about the Medicare-related topic or product category you select below.

Important: Permission to Contact is not the same as a Scope of Appointment. If we schedule a personal marketing appointment to discuss specific Medicare Advantage or Prescription Drug Plan options, a separate Scope of Appointment may be required before that appointment.

This form does not enroll you in any plan, does not obligate you to buy anything, and does not affect your current or future Medicare enrollment.

Please do not enter your Medicare number, Social Security number, prescription list, medical conditions, banking information, or other private health information on this form.

Complete the Permission to Contact Form

Fields marked with * are required.

Your Information

First Name *

Last Name *

Phone *

City

State *

ZIP Code *

How may we contact you? *

Select each contact method you authorize.

Phone call – You authorize TCG Insurance Solutions to call you at the phone number provided.

Voicemail – You authorize TCG Insurance Solutions to leave a voicemail if you are unavailable.

Text message – You authorize TCG Insurance Solutions to send text messages to the phone number provided. Message and data rates may apply.

Email – You authorize TCG Insurance Solutions to email you at the email address provided.

What are you requesting information about? *

Select the topic or product category you want to be contacted about.

General Medicare questions – Questions about Medicare timing, enrollment periods, Original Medicare, or how the basic pieces work.

Medicare Supplement Insurance — Medigap – Coverage that may help pay certain out-of-pocket costs with Original Medicare.

Medicare Advantage Plans — Part C –Medicare health plans offered by private companies that contract with Medicare.

Medicare Prescription Drug Plans — Part D –Plans that help cover prescription drug costs.

Dental, vision, and hearing coverage – Additional coverage options that may be available separately or with certain plans.

Best time to contact you

Preferred time of day

Preferred date, if any

Optional question

Please do not submit sensitive information.
Do not include your Medicare number, Social Security number, banking information, prescription list, medical conditions, or private health information on this form.

Permission to Contact

I give Permission to Contact. *
By submitting this form, I give Paul Carrigan / TCG Insurance Solutions permission to contact me using the contact method(s) I selected about the Medicare-related topic(s) I selected. I understand this permission does not enroll me in a plan, does not obligate me to buy anything, and may be withdrawn by telling TCG Insurance Solutions to stop contacting me.

Electronic Signature *

Signature Date *

Agent Information

Paul Carrigan
TCG Insurance Solutions
Website: www.TCGsolutions.us
Phone: 913-837-0434
Email: tcginsurancesolutions@gmail.com

Required TPMO Disclaimer

We do not offer every plan available in your area. Currently we represent 5 organizations which offer 34 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

What happens after you submit this form?

TCG Insurance Solutions may contact you using the method(s) you selected.
The contact should be limited to the topic(s) you requested.
If a specific Medicare Advantage or Part D plan discussion is scheduled, a separate Scope of Appointment may be needed before that appointment.
You may ask TCG Insurance Solutions to stop contacting you at any time.

Medicare Permission to Contact