Medicare.gov Account Authorization Form

Name: Mighty
Address: 50 Louis St NW #520, Grand Rapids, MI, 49504, US
Telephone: +1 (616) 222-0778
Price range: $$

If you are interested in meeting with one of our SHIP Counselors to discuss your Medicare options, please complete this form (along with the Medicare Worksheet) and return to the Resource Center. Forms can be sent to: 480 State Street, Holland, MI 49423