Silver Service Agreement | Medicare Plan Advocates Inc.

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Beneficiary Information

Full Name:

POA or Legal Representative (if applicable):

Address:

Email Address:

Phone Number:

Responsibilities Confirmation

I confirm that I have set up my Medicare.gov account, know my username and password, and have verified it is working.

I have a current list of my medications and dosages, including prescription creams, eye drops, inhalers, and occasional/periodic medications.

I understand I should not include vitamins, OTC items, or items administered in a doctor's office (Part B).

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Service Description Acknowledgment

By signing this agreement, I understand:

I am purchasing a 30-minute Medicare Part D consultation to analyze my medications and assist with self-enrollment on Medicare.gov.
This service does not guarantee specific medication costs but provides an estimate based on Medicare.gov.
There is no ongoing support after this session (self-enrolled plan)

Payment & Non-Repayment Policy

I understand that full payment is required prior to scheduling my appointment, even if I remain on my current plan.

I acknowledge that if I miss my initial meeting, one reschedule will be offered. Missing the rescheduled meeting results in forfeiture of my payment.

I understand no refunds will be given except for serious extenuating circumstances (e.g., hospitalization).

Disclaimers

I acknowledge that MPA is an independent consultant, not an employee or agent of Medicare.

Information I provide is for analysis purposes only and will not be stored or shared.

I retain full responsibility for choosing and enrolling in my Medicare Part D plan.

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Payment Information

Payment will be completed on the secure checkout page after submitting this form.

Consent to Terms

I agree to the Privacy Policy and Terms of Use.

I confirm that I am purchasing this service knowingly and voluntarily.

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Signature

You are asked to type your full legal name below. This serves as your digital signature confirming agreement to all terms above.

Signature (Type your full name):

Date:

Silver Plan — Quick Check (30-minute session)