Who is filling out this form?¿Quién esta llenando el formulario?
Contact Information Información de Contacto
By clicking and submitting this form with my name, phone number, and e-mail address, I agree that I am at least 18 years of age. I understand and consent to receive phone calls and e-mails (even if that phone number is on any Do Not Call Registry or is a mobile number) from 5 Star Medical Consulting or it’s affiliates. I authorize 5 Star Medical Consulting to connect me with a licensed insurance agent and I understand that I am under no obligation to purchase insurance. Should I apply for a Medicare plan using these services, I understand that the agent will be compensated by the Medicare plan I choose.
For more details, see our Privacy Policy.
Al hacer clic y enviar este formulario con mi nombre, número de teléfono y dirección de correo electrónico, acepto que tengo al menos 18 años de edad. Entiendo y doy mi consentimiento para recibir llamadas telefónicas y correos electrónicos (incluso si ese número de teléfono está en algún Registro de No Llamar o es un número de teléfono móvil) de 5 Star Medical Consulting o sus afiliados. Autorizo a 5 Star Medical Consulting a conectarme con un agente de seguros autorizado y entiendo que no tengo ninguna obligación de adquirir un seguro. Si solicito un plan de Medicare usando estos servicios, entiendo que el agente será compensado por el plan de Medicare que elija. Para obtener más detalles, consulte nuestra Política de Privacidad..
Patient Information
Referrer Information
Provider Information
Expedite Processing (Check if priority handling of the request is needed)
By clicking and submitting this form I affirm that I received consent to act on behalf of the patient. I understand that by including the name, phone number, and e-mail address of the patient, I am requesting contact on behalf of the patient by 5 Star Medical Consulting who will connect the patient with a licensed insurance agent to discuss insurance services and options. The patient is under no obligation to purchase insurance. Should they apply for a Medicare plan using those services, they understand that the agent will be compensated by the Medicare plan they choose. I acknowledge that this authorization does not allow 5 Star Medical Consulting to enroll the patient in marketing campaigns, nor will the patient receive unsolicited phone calls or e-mails about services beyond the scope of this authorized contact.
