Contact HICAP Form

Contact HICAP Form

"*" indicates required fields

We can help you with Medicare. HICAP, the Health Insurance Counseling and Advocacy Program, provides free, unbiased education, counseling, and advocacy about Medicare and related health insurance.

Please use this form to submit a question or a request for assistance with Medicare. We generally try to respond within 2 to 3 business days. However at times it may take up to 5 business days.

Complete the form below. An *asterisk indicates a required field. Do not put any personal information on this form, such as Medicare number or insurance member number.

Client's Name*

First Name Last Name

Client's Year of Birth (example: 1947)*

Client's Zip Code*

If you are contacting us on behalf of someone else, enter your name here.

Your Email Address*

Enter Email Confirm Email

Your Phone*

Enter the best phone number to be reached on week days.

How do you prefer HICAP to contact you?*

(check all that apply)

PHONE

If you requested a reply by phone, please provide time windows (date and time) you will be available to answer your phone over the next few business days. We will try to call you during one of those times. (It may occassionally take more than 3 days.)

(examples: "weekday mornings from 9 to 12", or "Tuesday and Wednesday after 3 pm", or "any time")

Would you use ZOOM Video Conferencing to talk with a Counselor?

YES

How did you hear about Contra Costa HICAP?*

Please briefly explain your issue.
DO NOT give any personal information (i.e. Medicare number, birth date, etc).
We will contact you to collect more details.

Description of issue

PLEASE NOTE: It may take several days for you to hear from us. Please do not submit a second form, or call our phone number. Multiple requests from the same person will slow down the response. Thank you for your cooperation.

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Name

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

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For FREE and UNBIASED help with Medicare, please CONTACT US