Medicare By Phone Payment Form

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Medicare By Phone Payment

Registration/Payment

By checking this box, I acknowledge that I have read, fully understand, and agree to the requirements, terms, and conditions for participating agents of the Medicare By Phone Program.*
- I agree
Name on Card*
First Last
Email*
Phone*
Billing Address*
Street Address Address Line 2 City State ZIP Code
Type of Card*
- Visa
- Master Card
- Discover
Credit Card Number*
Security Code*
Expiration Date*
By Checking this box you are authorizing recurring monthly payments of $695.*
- Authorization
What States are you Licensed in?*

Credit Cardholder understands that this is a RECURRING PAYMENT that will draft on the 5th of every month. Payments can only be canceled in writing. If for any reason, there is a balance due, it must be paid at the time of cancellation. NO REFUNDS, EXCHANGES, or REPLACEMENTS. Upon termination of this Agreement for any reason, Credit Cardholder shall not be entitled to any refund of any previously paid monthly fees, or any portion thereof.

Medicare By Phone Payment Form

Medicare By Phone Payment

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