AEP Form

AEP Material Intake Form 2024

In Order to Sell Leads and Calls Through the RPM Platform During Open Enrollment All Sources Must Provide Updated Documentation Requested in the Form Below.

AEP Material Intake Form 2024

Company Name(Required)

Multi select(Required)

Traffic Split(Required)

How Much Traffic is Aggregated?

Aggregate Traffic(Required)

Please list all Aggregated URLs

Traffic Type(Required)

Please indicate all types of traffic you intend to sell via the PX Platform

URLs with SMIDs(Required)

Drop files here or

Accepted file types: xlsx, xlsm, xls, ods, csv, tsv, Max. file size: 12 GB.

Please upload an excel sheet with all URLs you plan to collect call and lead data from and include the corresponding SMID.

CMS Approval

Please Indicate if all URLs and Creatives are CMS Approved

Documentation(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, , Max. file size: 12 GB.

Please Attach Screenshot of CMS Documentation

Do you plan on going through the CMS Approval Process? If no, please explain your reasons.(Required)

Date Submitted(Required)

Please Indicate the Date You Submitted Materials to CMS for Approval

CMS Sponsor Name(Required)

Please List the Name of Your CMS Sponsor

Creatives(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 12 GB.

Please Upload All Creatives Used to Drive Medicare Traffic

Creative Types

Please Indicate All Creatives Types Included in the Package

Scripts

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 12 GB.

Please Attach all Scripts Being Used by Call Centers

Call Center Location(Required)

Please Indicate the Location of Your Call Center

What is the Location of Your OffShore Call Center(Required)

Call Center Hours(Required)

Please Indicate All Call Center Hours by Location

Call Center Hours(Required)

Please Indicate All Call Center Hours by Location

Carrier Opt-Ins

Please Indicate All Carriers Who Have Already Opt-In

Carrier Opt-In Documentation(Required)

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 12 GB.

Please Provide Screenshots of Carrier Opt-Ins

I hereby affirm that all information provided on this form is true and accurate to the best of my knowledge. I understand that any intentional misrepresentation or omission of facts may result in penalties as determined by law or other applicable regulations.(Required)

Name(Required)

Please Add Your First and Last Name For Our Records

Email(Required)

Please Add Your Email

Date Signed

Comments

This field is for validation purposes and should be left unchanged.

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AEP Form

AEP Material Intake Form 2024

AEP Material Intake Form 2024

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