Permission to Contact Form - OK - American Health Plans

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

Please enable JavaScript in your browser to complete this form.

Authorized Representative Name

First

Last

Phone

Best Time to Call

Address

Address Line 1

City

State

Zip Code

Beneficiary's Name

First

Last

Relationship

Facility Name

Signature

Clear Signature

Checkboxes

Completed by facility staff

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

Y0144_PRMCNTCRD_C