Medicare + Medicaid in One Easy Plan

YES! I want information on the CareSource® MyCare Ohio (HMO D-SNP) plan which may help lower my health care costs! There is no cost to submit this form.

First Name:

Last Name:

Address Line 1:

Address Line 2:

City:

State:

ZIP Code:

Phone:

Email Address:

By clicking "Contact Me," I grant permission for a licensed sales agent to contact me.

By submitting your information on this form, you agree that a licensed sales representative from CareSource may contact you by phone, SMS, email or mail to answer your questions or provide additional information about our CareSource MyCare Ohio plan. Should you request a representative to come to your home or other setting for a face-to-face sales meeting, a scope of appointment form must be signed or a voice recorded scope of appointment form must be completed prior to the appointment time. The representative who will discuss products with you is either employed or contracted by the plan and may be paid based on your enrollment. They do not work for the Federal government. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. This agreement is not a condition of enrollment.

H6396_OH-SNP-C-5597076_C