Contact Email Form

Medicare Assured^® Enrollment Contact Form

If you are a Current Member and have a question please use the following form: Medicare Assured^® Member Contact Form.

If you have both cards below you can fill out this form and a representative will contact you about enrollment:

Yes, please send me information on Gateway Health Plan Medicare Assured^®.
Yes, a Plan representative may call me to discuss Gateway Health Plan Medicare Assured^®.
Yes, I have both Medicare and Medicaid
* First Name
* Last Name
Street Address
City
State
Zip
County
Phone Number	ex. 999-999-9999
Best Time to Contact you?
I am over 13 years old. Under the Children’s Online Privacy Protection Act (COPPA) of 1998 Gateway Health Plan^® can only accept information from individuals over the age of 13.

Medicare Assured® Enrollment Contact Form

Medicare Assured^® Enrollment Contact Form