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SHIBA Contact FormMichael Mosin2021-09-29T13:35:21-07:00

SHIBA Contact Request

Submit a request for a SHIBA member to contact you.
Please SELECT ONE (1) of the options from the dropdown menu.
Name(Required)
Please enter your FULL NAME (first & last) by which you prefer to be addressed.
Residence(Required)
Please enter the CITY and ZIP CODE associated with your / the beneficiary's residential address.
Preferred Contact Method(Required)
Please SELECT ONE (1) of the options listed below:
Email
Please enter the email address you would prefer us to contact you or send materials.
Please enter the PHONE NUMBER you prefer for us to call to reach you.
When we call, can we leave a voice message?
If "YES", please make sure the voicemail inbox is properly set up & empty enough to receive new messages.
Does the the Medicare beneficiary have a Medicare.gov Account set up?
It is highly recommended for eligible Medicare beneficiaries to have a Medicare.gov account, as it is very helpful & saves time for both the beneficiaries & the advisors.
Please SELECT ONE (1) of the options from the dropdown menu.
Please provide any additional relevant information or briefly summarize your needs. (Maximum 300 characters)
This field is for validation purposes and should be left unchanged.
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