Referral Partner Portal

Refer a Client to Active Medicare Solutions

Thank you for trusting Active Medicare Solutions. Complete the secure referral form below, and our Client Services team will follow up with your referral.

Need assistance? Call us at (804) 874-6000.

Secure submission Confidential handling Reviewed by Client Services

Referral Information

Please provide your business name and the client’s basic contact information.

Referral Source

Enter the name of the business or organization making the referral.

First Name

Last Name

Phone

Date of Birth

Format: MM.DD.YYYY

Zip Code

Referral Authorization I confirm that the client has given permission for their information to be shared with Active Medicare Solutions and for the Active Medicare Solutions team to contact them.

The information submitted through this form will be used only to process the referral and contact the prospective client. Please do not include Social Security numbers, Medicare numbers, medical records, or other sensitive health information. See our Privacy Policy.