Name *

First Name

Last Name

Preferred Language *

If you require services in a language other than English, Spanish, or Portuguese, please choose other and list the language. Over-the-phone interpreter services are available.

English

Spanish

Portuguese

Other

Type of Insurance You're Applying for *

Marketplace/Seguro Médico

Medicare (65+ or disabled)

Medicaid (KanCare/MO Healthnet)

I don't know

Would you prefer an online or in-person appointment? *

Online

In-person (only available for people near or in the KC Metro)

Permission to Contact *

By signing this form, you authorize a licensed sales agent from Kansas Assistance Network to contact you on your phone, cell phone, or email to provide additional information about products or services now or during the next enrollment period. You may contact us to change your preferences at any time. The person that will be contacting you is either employed or contracted by a Medicare plan, not the Federal government. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage plan, prescription drug plan, or other Medicare plan.

Yes

No