First Name *

Last Name *

Date of birth *

Tip: Click the Year first, then month lastly, the day

Phone *

Email *

Gender

Address

City

State

Postal code

I consent to receive marketing communications from Health Wealth Simplified DBA Mere as described in our Privacy Policy. I understand that I can unsubscribe at any time.I consent to receive communications from Health Wealth Simplified LLC, DBA Mere, including but not limited to SMS notifications, emails, ringless voicemails, and phone calls. These communications may include information about health insurance plans, updates, and promotional offers. Some communications may be automated or managed by an AI bot. Message frequency may vary. Message and data rates may apply. You can opt out of these communications at any time by replying STOP to any message.

Medicare ID Number

Part A Effective Date

Part B Effective Date

Medicaid *

Social Security Number

*IF YOU PUT "YES" TO MEDICAID, PLEASE PROVIDE YOUR SOCIAL SECURITY NUMBER

LIS/Extra Help *

Veteran *

Source of Income and Assets *

POA

Emergency Contact:

Referral Source

Option Review

Please take note: Each individual looking for coverage needs their own form completed. Thank you!

Medicare Enrollment Information

Please fill out the form below so that we can present

accurate information pertaining to your Medicare options.