Guide Savings Form · Custom Portal

Request Your Guide To Savings

(* Required fields)

Fill out the form below to receive a free Medicare information guide either by email or postal delivery.

Requested Date

Portal URL

Delivery method

Email
Postal

By providing Independence Blue Cross (Independence) with your email address, you agree to allow Independence to contact you via email. You may opt out at any time.

Email Address *

First Name

Last Name

Phone Number

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Home phone
Mobile phone

By providing Independence with your phone number, you agree to allow Independence to contact you via telephone call and/or text message regarding the kit you requested. You may opt out at any time.

Address

Address 2

City

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County

Zip

Kit Codes

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Independence Blue Cross offers products through its subsidiaries Independence Assurance Company, Independence Hospital Indemnity Plan, Keystone Health Plan East, and QCC Insurance Company — independent licensees of the Blue Cross and Blue Shield Association.

Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Bucks, Chester, Delaware, Montgomery, and Philadelphia counties of Pennsylvania.

Independence Blue Cross complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-275-2583 (TTY/TDD: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務. 請致電 1-800-275-2583 TTY/TDD: 711).