www.medicare.gov Open in urlscan Pro
2a02:26f0:480:6b3::348  Public Scan

Form analysis
4 forms found in the DOM

GET /search/medicare

<form action="/search/medicare" method="get" id="search-block-form" accept-charset="UTF-8" role="search" class="search-form search-block-form" aria-hidden="true">
  <div class="js-form-item form-item js-form-type-search form-type-search js-form-item-keys form-item-keys form-no-label">
    <label for="edit-keys" class="m-evo-label ds-c-label visually-hidden"><span>Search</span></label>
    <input title="Enter the terms you wish to search for." data-drupal-selector="edit-keys" type="search" id="edit-keys" name="keys" value="" size="15" maxlength="128" class="form-search">
  </div>
  <div data-drupal-selector="edit-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-actions">
    <input data-drupal-selector="edit-submit" type="submit" id="edit-submit" value="Search" class="button js-form-submit form-submit ds-c-button ds-c-button--solid">
  </div>
</form>

POST /

<form class="medicare-email-signup-form" data-drupal-selector="medicare-email-signup-form-2" action="/" method="post" id="medicare-email-signup-form--2" accept-charset="UTF-8">
  <input data-drupal-selector="edit-prod" type="hidden" name="prod" value="prod">
  <input data-drupal-selector="edit-state-question-id" type="hidden" name="state_question_id" value="65497">
  <input data-drupal-selector="edit-group-question-id" type="hidden" name="group_question_id" value="74299">
  <input data-drupal-selector="edit-email" type="hidden" name="email" value="">
  <fieldset class="ds-c-fieldset ds-u-margin-top--0 js-form-item form-item js-form-wrapper form-wrapper" data-drupal-selector="edit-step1" id="edit-step1--2">
    <legend>
      <span class="fieldset-legend"></span>
    </legend>
    <div class="fieldset-wrapper">
      <div class="js-form-item form-item js-form-type-email form-type-email js-form-item-step1-email form-item-step1-email">
        <label for="edit-step1-email--2" class="m-evo-label ds-c-label js-form-required form-required"><span>Enter your email address</span></label>
        <input class="ds-c-field form-email required" autocomplete="off" data-drupal-selector="edit-step1-email" type="email" id="edit-step1-email--2" name="step1[email]" value="" size="60" maxlength="254" placeholder="name@example.com"
          required="required">
      </div>
      <div class="js-form-item form-item js-form-type-checkbox form-type-checkbox js-form-item-step1-consent form-item-step1-consent">
        <input class="ds-c-choice form-checkbox required" data-drupal-selector="edit-step1-consent" type="checkbox" id="edit-step1-consent--2" name="step1[consent]" value="1" required="required">
        <label for="edit-step1-consent--2" class="m-evo-label ds-c-label option js-form-required form-required"><span><span> By checking this box, you consent to our <a href="/privacy-policy">data privacy policy</a>. </span></span></label>
      </div>
    </div>
  </fieldset>
  <input autocomplete="off" data-drupal-selector="form-lfjpxwism7gklduxtgczwtehvwerr-6deb5lobpplsw" type="hidden" name="form_build_id" value="form-LfjPxwIsM7GKLDuxtGczWteHVweRr_6DeB5LObPplSw">
  <input data-drupal-selector="edit-medicare-email-signup-form-2" type="hidden" name="form_id" value="medicare_email_signup_form">
  <div data-drupal-selector="edit-emailsignup-actions" class="form-actions js-form-wrapper form-wrapper" id="edit-emailsignup-actions--2">
    <input data-drupal-selector="edit-emailsignup-actions-next1" type="submit" id="edit-emailsignup-actions-next1--2" name="op" value="Next Step" class="button button--primary js-form-submit form-submit ds-c-button ds-c-button--solid"
      data-once="drupal-ajax">
  </div>
</form>

<form novalidate="">
  <input name="e" type="email" required="" id="prefix-emailInput" aria-labelledby="prefix-overlay-label" placeholder="">
  <div id="prefix-consent-outer">
    <input name="consent" type="checkbox" id="prefix-consentPolicyInput"> <label for="prefix-consentPolicyInput" id="prefix-consentPolicyLabel">By checking this box, you consent to our
      <a href="https://www.medicare.gov/privacy-policy" target="_blank" rel="noopener noreferrer">data privacy policy</a>.</label>
  </div>
  <input type="submit" value="Next Step" id="prefix-submitButton">
</form>

<form id="prefix-formStepForm" novalidate="">
  <label for="q_74299" style="text-transform: uppercase;">Please tell us which best describes you</label>
  <div id="prefix-questions"><select name="q_74299" class="prefix-questionId" id="prefix-q_74299" disabled="" tabindex="-1">
      <option value="228746">I currently have Medicare</option>
      <option value="228747">I will have Medicare soon (in less than 3 years) </option>
      <option value="228748">I am a caregiver for someone who has Medicare</option>
      <option value="228749">Other </option>
    </select></div>
  <label for="q_65497" style="text-transform: uppercase;">Select your state</label>
  <div id="prefix-questions"><select name="q_65497" id="prefix-q_65497" class="prefix-questionId" disabled="" tabindex="-1">
      <option value="" selected="" disabled="">Select your state</option>
      <option value="193817">Alabama</option>
      <option value="193818">Alaska</option>
      <option value="193819">Arizona</option>
      <option value="193820">Arkansas</option>
      <option value="193821">California</option>
      <option value="193822">Colorado</option>
      <option value="193823">Connecticut</option>
      <option value="193824">Delaware</option>
      <option value="193825">District of Columbia</option>
      <option value="193826">Florida</option>
      <option value="193827">Georgia</option>
      <option value="193828">Hawaii</option>
      <option value="193829">Idaho</option>
      <option value="193830">Illinois</option>
      <option value="193831">Indiana</option>
      <option value="193832">Iowa</option>
      <option value="193833">Kansas</option>
      <option value="193834">Kentucky</option>
      <option value="193835">Louisiana</option>
      <option value="193836">Maine</option>
      <option value="193837">Maryland</option>
      <option value="193838">Massachusetts</option>
      <option value="193839">Michigan</option>
      <option value="193840">Minnesota</option>
      <option value="193841">Mississippi</option>
      <option value="193842">Missouri</option>
      <option value="193843">Montana</option>
      <option value="193844">Nebraska</option>
      <option value="193845">Nevada</option>
      <option value="193846">New Hampshire</option>
      <option value="193847">New Jersey</option>
      <option value="193848">New Mexico</option>
      <option value="193849">New York</option>
      <option value="193850">North Carolina</option>
      <option value="193851">North Dakota</option>
      <option value="193852">Ohio</option>
      <option value="193853">Oklahoma</option>
      <option value="193854">Oregon</option>
      <option value="193855">Pennsylvania</option>
      <option value="193856">Rhode Island</option>
      <option value="193857">South Carolina</option>
      <option value="193858">South Dakota</option>
      <option value="193859">Tennessee</option>
      <option value="193860">Texas</option>
      <option value="193861">Utah</option>
      <option value="193862">Vermont</option>
      <option value="193863">Virginia</option>
      <option value="193864">Washington</option>
      <option value="193865">West Virginia</option>
      <option value="193866">Wisconsin</option>
      <option value="193867">Wyoming</option>
      <option value="193868">Puerto Rico</option>
      <option value="193869">U.S. Virgin Islands</option>
      <option value="193870">American Samoa</option>
      <option value="193871">Guam</option>
      <option value="193872">Northern Mariana Islands</option>
      <option value="239669">Other</option>
    </select></div>
  <input type="submit" value="Continue" id="prefix-formStep-submitButton" tabindex="-1">
</form>

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GET INFORMATION THAT'S SPECIFIC TO YOU

Please tell us which best describes you
I currently have Medicare I will have Medicare soon (in less than 3 years) I am
a caregiver for someone who has Medicare Other
Select your state
Select your state Alabama Alaska Arizona Arkansas California Colorado
Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois
Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan
Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey
New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon
Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah
Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico U.S.
Virgin Islands American Samoa Guam Northern Mariana Islands Other