Take this important survey and get helpful planning tools.

Complete the survey below, and get your FREE Medicare planning tools today!

* Indicates a required field.

1. Which statement best describes you?*

I am already retired.
I am retiring soon.
I am continuing to work.

If you plan to continue working, when do you anticipate retiring?*

Month

Year

2. Do you already have Medicare?*

Yes
No
I'm not sure

If no, which statement best describes when you plan to enroll in Medicare?

In the next 3-6 months
In the next 6-12 months
In the next 12-18 months
Later than 18 months

3. Are you eligible to receive health coverage from a pension plan or your employer when you retire?

Yes
No
I’m not sure

First Name*

Middle Initial

Last Name*

Address 1*

Address 2

City*

State

ZIP Code*

Email Address*

Phone Number

Date of birth:

I'd like my FREE Welcome to Medicare planning tools also mailed to me.

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Presented by

montage health and salinas valley memorial healthcare system

Aspire Health Plan is a Medicare Advantage HMO plan sponsor with a Medicare contract. Enrollment in Aspire Health Plan depends on contract renewal. Other providers are available in our network. Aspire Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. For accommodations of persons with special needs at meetings call (866) 799-9732 (TTY users call 711).

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Page last updated: 2/22/2024

Sorry for the inconvenience. We are currently performing a short maintenance update on this enrollment site. We will be back online, Sunday, February 24th at 6am.

Please return tomorrow after 6am or call
(866) 799-9732 between 8am – 8pm