Open Enrollment Medicare Appointment Request

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Please fill out this form in order to request a Medicare Counseling Appointment with a certified SHIIP counselor. If you have already filled out the form to be on the waitlist you do not need to leave a phone message as well. Someone will call you back in 2-3 business days to set this appointment.

Email Address *

First and Last Name *

Age *

Birthdate *

Zip Code *

Phone Number

*Please enter in this format:

xxx-xxx-xxxx

Are you an employee or retiree of the State of North Carolina? *

Yes

Are you a Veteran? *

Yes

Do you take more than 10 medications on a daily basis? *

Yes

Reason for Appointment *

I am turning 65 in 2026

I am turning 65 in 2027

To review my Medicare Advantage coverage during the Annual Open Enrollment Period.

To review my Part D drug coverage during the Annual Open Enrollment Period.

I would like to look into returning to original Medicare with a Supplement and a Part D drug plan.

I am retiring and going onto Medicare in 2026

Other:

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