MedicareRx Access Network of Illinois

Tell your story here

We Need Your Permission…here’s how we’ll use your story to let other seniors know help is available!

By checking below, I will allow the Medicare Rx Access Network and those acting within its authority the right to create, reproduce, publish, circulate, broadcast, distribute, or otherwise use, in whole or in part, my name, address, story, or testimonial, and any picture, photograph, videotape and/or audio tape of me or my “story” for the purpose of sharing my enrollment experience in the new Medicare Part D Prescription Drug Program, and helping other seniors enroll and enjoy the same benefits.

I have been informed that by signing below, this form covers the use of my story in any media of advertising or publicity, such as on the radio, television, internet, or print, and by distributing it to the media, members of Congress, or any other entity or person.

I understand that no material changes will be made to my story, but minor editorial changes may be made without my permission or review of the final product. I also understand that this is a release of all claims against the Network and those acting within its authority.

Check to give permission for MedicareRx Access Network to use this testimonial.