Schedule a Home Appointment

Have a Touchstone Health Representive come to your home to explore your plan options. Please fill out the information below, and a Touchstone Health Representative will contact you to confirm your appointment time.

Prefix (Mr, Mrs., Ms):
First Name:
Last Name:
Home Address 1:
Home Address 2:
Home City:
Home State:
Home Zip:
Home County:
Phone Number:
Email Address:	Your email will be used ONLY to confirm your request for an in-home appointment from a Touchstone Health representative. We will NOT share your email address nor will we add you to our mailing list.
What day would you like your home visit?	May 2012      -      June 2012 May S M T W T F S     1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31                   June S M T W T F S           1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
What time would you like your home visit?	Morning    Afternoon    Evening
Appointment Confirmation:	By checking this box, you are agreeing to a sales meeting from a sales agent to discuss Touchstone Health Medicare Advantage Plans. The person that will be discussing plan options with you is either employed or contracted by a Medicare health plan or prescription drug plan that is not the Federal government, and they may be compensated based on your enrollment in a plan. Signing this does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.