"You Focus on Care. We Focus on Coverage."

- Permission to Contact

Patient Enrollment - Information Request: Virginia Insurance Partners LLC (DBA VIP Insurance Group) helps your patients navigate Medicare and health plan options. By completing this form, you are giving a licensed agent permission to contact you to discuss your coverage.

First Name *

Last Name *

Phone *

Secondary/Home Contact Number

Clinic Patient Address *

Email *

Receptionist Name *

Internal Staff Notes

Appointment_Consent *

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Marketing Consent *

I agree to receive marketing and promotional messages from Virginia Insurance Partners LLC. Msg/data rates apply. Reply STOP to opt-out.