By filling out this form, you are agreeing to a sales meeting or receiving a call from a sales representative to discuss the specific types of products Gold Kidney of Arizona offers. The person who will be discussing plan options with you is employed or contracted by a Medicare Health Plan that is not the Federal government, and they may be compensated based on your enrollment in a plan. This is not an application. Signing this form does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage or other Medicare plan. The Centers for Medicare and Medicaid Services (CMS) require agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure an understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or their authorized representative. Gold Kidney of Arizona, Inc. complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Gold Kidney Health Plan Inc. is an HMO, HMO C-SNP, HMO-POS C-SNP with a Medicare contract. Enrollment and gold kidney health plan depends on contract renewal