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Texas Health Insurance Group

Texas Health Insurance Group

Licensed Insurance Agents Serving Texas Families

Consent to Contact

Permission to Contact Form

Please fill out the form below so we can contact you about health insurance plans.

Personal Information

Contact Information

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Medicare Eligibility

Are you currently Medicare eligible?

I'm Interested In

Plan availability may vary by location. Select all that apply.

Consent & Signature

By providing my email address or telephone number, I agree to allow a licensed sales representative from Texas Health Insurance Group to contact me regarding information related to health insurance plans, products, services, and/or educational information related to health care. I understand that I may revoke this consent at any time by contacting the agent directly.

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Your information will be provided to a licensed insurance agent who may contact you about health insurance options. Submission is not required to receive insurance information. This is a solicitation of insurance. You may revoke this consent at any time by contacting Jay Gutierrez Insurance Agency, Inc. at (361) 267-5977.