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Why this form exists: Federal regulations require that individuals provide written permission before a licensed insurance agent may contact them about Medicare. This form records your consent. You are not required to complete it, and doing so does not obligate you to purchase anything.
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Legacy Wealth Services is not affiliated with or endorsed by Medicare, the Social Security Administration, or the federal government. Independent insurance agency. OR License #18847712. This form is voluntary; you are not required to complete it to receive Medicare information. Submission constitutes an electronic signature under the ESIGN Act.