Medicare Appointment Request Waitlist

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Please fill out this form in order to go onto the waitlist for a Medicare Counseling Appointment with a certified SHIIP counselor. We are experiencing a high volume of calls for appointments and are now operating with a waitlist to fill appointments. If you have already filled out the form to be on the waitlist you do not need to leave a phone message as well.

First and Last Name *

Age *

Birthdate *

Zip Code *

Phone Number *

Email Address

Reason for Appointment: *

I need an appointment during the Annual Enrollment Period appointment to review my coverage.

I am turning 65 in 2025

I am retiring and going onto Medicare in 2025

Other:

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