HICAP SERVICES

Appointment Form

APPOINTMENT FORM

Request a confidential Medicare counseling appointment

Complete the form below to ask our team to contact you about availability.

Free • Confidential • Unbiased

GET STARTED

Request an appointment

Submit the form below and a HICAP staff member will contact you to discuss availability. Submitting a request does not confirm an appointment.

Full Name * Phone Number * Email Address (Optional) County * ZIP Code (Optional) Date of Birth (Optional) Preferred Appointment Date (Optional) Preferred Time of Day

Issue (Optional)

Briefly describe your question. Please do not include Medicare numbers, Social Security numbers, or medical details.

Please do not include Medicare numbers, Social Security numbers, or medical information. Submitting this form does not confirm an appointment.

HERE TO HELP

Questions about Medicare?

Speak with a HICAP counselor for free, unbiased guidance.

Request an appointment