Permission to Contact Form - IN - American Health Plans

Fill out the form below to get more information about our Medicare Advantage plan offered in Indiana.

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Authorized Representative Name

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Last

Phone

Best Time to Call

Address

Address Line 1

City

State

Zip Code

Beneficiary's Name

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Last

Relationship

Facility Name

Signature

Clear Signature

Checkboxes

Completed by facility staff

I understand an agent may contact me. American Health Advantage of Indiana, offered by American Health Plan of Indiana, Inc, is a Health Maintenance Organization (HMO) with a Medicare Contract. Enrollment in American Health Advantage of Indiana depends on contract renewal. This plan is available to Medicare recipients who reside in a contracted nursing home or live at home and Indiana has certified that you need the type of care that is usually provided in a nursing home.

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