Veteran's are getting up to $1,200 off their Part B Premium Annually

FIND OUT HOW BELOW

First Name *

Last Name *

Date of Birth (MM/DD/YYYY) *

Are you a veteran? *

Yes

No

Do you have any of the following coverages? *

Tricare for Life (20 years of service)

ChampVA (Spouse of Retired Military)

I have neither of these

What branch of the military did you serve in? *

Army

Navy

Air Force

Marines

Coast Guard

Do you have Medicare Part A AND Part B?

Yes

No

Phone *

Do you use the VA for your medication coverage? *

Yes

No

Veteran Disclosure: Check box to verify *

I verify that all my answers are true to the best of my knowledge.

Signature *

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