{"id":3322,"date":"2026-08-13T12:07:52","date_gmt":"2026-08-13T17:07:52","guid":{"rendered":"https:\/\/sierraplanchoice.com\/?page_id=3322"},"modified":"2026-08-13T12:24:10","modified_gmt":"2026-08-13T17:24:10","slug":"form","status":"publish","type":"page","link":"https:\/\/sierraplanchoice.com\/es\/form\/","title":{"rendered":"Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3322\" class=\"elementor elementor-3322\">\n\t\t\t\t<div class=\"elementor-element elementor-element-57f83d3 e-flex e-con-boxed e-con e-parent\" data-id=\"57f83d3\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3eb8b43 elementor-widget elementor-widget-shortcode\" data-id=\"3eb8b43\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<link rel='stylesheet' id='gpc-form-css-css' href='https:\/\/sierraplanchoice.com\/wp-content\/plugins\/golden-plan-choice-form\/assets\/css\/gpc-form.css?ver=1.0.0' media='all' \/>\n<style id=\"gpc-form-css-inline-css\">\n:root{--gpc-primary:#F5A623;--gpc-primary-dark:#D98812;--gpc-secondary:#F7C873;--gpc-gray:#8A8D8F;--gpc-dark:#231F20;}\n\/*# sourceURL=gpc-form-css-inline-css *\/\n<\/style>\n\t\t<div class=\"elementor-shortcode\">\t\t\t\t\t<style id=\"gpc-form-inline-css\">\n\t\t\t\t\/* Golden Plan Choice - Formulario de Cancelaci\u00f3n\n   Paleta por defecto (sobrescrita por variables inline desde PHP) *\/\n:root {\n\t--gpc-primary: #F5A623;\n\t--gpc-primary-dark: #D98812;\n\t--gpc-secondary: #F7C873;\n\t--gpc-gray: #8A8D8F;\n\t--gpc-dark: #231F20;\n\t--gpc-bg: #FAFAF8;\n\t--gpc-border: #E8E4DC;\n\t--gpc-radius: 14px;\n}\n\n.gpc-form-wrapper * {\n\tbox-sizing: border-box;\n}\n\n.gpc-form-wrapper {\n\tfont-family: -apple-system, BlinkMacSystemFont, \"Segoe UI\", Roboto, Helvetica, Arial, sans-serif;\n\tmax-width: 880px;\n\tmargin: 32px auto;\n\tcolor: var(--gpc-dark);\n\tline-height: 1.55;\n}\n\n.gpc-form-card {\n\tbackground: #ffffff;\n\tborder-radius: calc(var(--gpc-radius) + 6px);\n\tbox-shadow: 0 10px 40px rgba(35, 31, 32, 0.08), 0 2px 8px rgba(35, 31, 32, 0.06);\n\toverflow: hidden;\n\tborder: 1px solid var(--gpc-border);\n}\n\n\/* ---------- Header ---------- *\/\n.gpc-form-header {\n\tbackground: linear-gradient(135deg, var(--gpc-primary) 0%, var(--gpc-secondary) 100%);\n\tpadding: 40px 36px 32px;\n\ttext-align: center;\n\tposition: relative;\n}\n\n.gpc-form-header::after {\n\tcontent: \"\";\n\tposition: absolute;\n\tleft: 0;\n\tright: 0;\n\tbottom: 0;\n\theight: 6px;\n\tbackground: linear-gradient(90deg, var(--gpc-gray), var(--gpc-primary-dark));\n}\n\n.gpc-logo {\n\tmax-width: 190px;\n\tmax-height: 110px;\n\twidth: auto;\n\theight: auto;\n\tmargin: 0 auto 18px;\n\tdisplay: block;\n\tfilter: drop-shadow(0 4px 10px rgba(0,0,0,0.12));\n}\n\n.gpc-agency-name {\n\tcolor: #fff;\n\tfont-size: 26px;\n\tmargin: 0 0 12px;\n\tfont-weight: 700;\n}\n\n.gpc-agency-contact {\n\tcolor: rgba(35,31,32,0.85);\n\tfont-size: 13.5px;\n\tmargin: 0 0 18px;\n\tdisplay: flex;\n\tflex-wrap: wrap;\n\tjustify-content: center;\n\tgap: 6px 18px;\n}\n\n.gpc-form-title {\n\tcolor: var(--gpc-dark);\n\tfont-size: 22px;\n\tfont-weight: 800;\n\tmargin: 6px auto 6px;\n\tmax-width: 640px;\n\tletter-spacing: -0.2px;\n}\n\n.gpc-form-subtitle {\n\tcolor: rgba(35,31,32,0.7);\n\tfont-size: 13px;\n\tmargin: 0;\n\tfont-style: italic;\n}\n\n\/* ---------- Sections ---------- *\/\n.gpc-form {\n\tpadding: 8px 36px 36px;\n}\n\n.gpc-section {\n\tpadding: 26px 0;\n\tborder-bottom: 1px solid var(--gpc-border);\n}\n\n.gpc-section:last-of-type {\n\tborder-bottom: none;\n}\n\n.gpc-section-highlight {\n\tbackground: linear-gradient(180deg, rgba(245,166,35,0.06), rgba(245,166,35,0));\n\tborder-radius: var(--gpc-radius);\n\tpadding: 26px 22px;\n\tmargin: 10px 0;\n}\n\n.gpc-section-title {\n\tdisplay: flex;\n\talign-items: center;\n\tgap: 12px;\n\tfont-size: 17px;\n\tfont-weight: 700;\n\tmargin: 0 0 16px;\n\tcolor: var(--gpc-dark);\n}\n\n.gpc-badge {\n\tdisplay: inline-flex;\n\talign-items: center;\n\tjustify-content: center;\n\twidth: 28px;\n\theight: 28px;\n\tmin-width: 28px;\n\tborder-radius: 50%;\n\tbackground: var(--gpc-primary);\n\tcolor: #fff;\n\tfont-size: 14px;\n\tfont-weight: 800;\n}\n\n.gpc-legal-text {\n\tfont-size: 13.5px;\n\tcolor: #4a4645;\n\tbackground: var(--gpc-bg);\n\tborder-left: 3px solid var(--gpc-secondary);\n\tpadding: 12px 16px;\n\tborder-radius: 0 8px 8px 0;\n\tmargin: 0 0 16px;\n}\n\n.gpc-legal-list, .gpc-services-list {\n\tmargin: 0 0 16px;\n\tpadding-left: 0;\n\tlist-style: none;\n}\n\n.gpc-legal-list li, .gpc-services-list li {\n\tfont-size: 13.5px;\n\tcolor: #4a4645;\n\tbackground: var(--gpc-bg);\n\tborder-left: 3px solid var(--gpc-gray);\n\tpadding: 12px 16px;\n\tborder-radius: 0 8px 8px 0;\n\tmargin-bottom: 10px;\n}\n\n.gpc-services-list li {\n\tborder-left-color: var(--gpc-primary);\n}\n\n\/* ---------- Grid & Fields ---------- *\/\n.gpc-grid {\n\tdisplay: grid;\n\tgrid-template-columns: 1fr 1fr;\n\tgap: 18px 20px;\n}\n\n.gpc-col-2 {\n\tgrid-column: 1 \/ -1;\n}\n\n.gpc-field {\n\tdisplay: flex;\n\tflex-direction: column;\n\tmargin-bottom: 4px;\n}\n\n.gpc-field label {\n\tfont-size: 13px;\n\tfont-weight: 600;\n\tmargin-bottom: 6px;\n\tcolor: var(--gpc-dark);\n}\n\n.gpc-field input[type=\"text\"],\n.gpc-field input[type=\"email\"],\n.gpc-field input[type=\"tel\"],\n.gpc-field input[type=\"date\"] {\n\tborder: 1.5px solid var(--gpc-border);\n\tborder-radius: 10px;\n\tpadding: 11px 14px;\n\tfont-size: 14.5px;\n\tbackground: #fff;\n\ttransition: border-color .15s ease, box-shadow .15s ease;\n\twidth: 100%;\n\tfont-family: inherit;\n\tcolor: var(--gpc-dark);\n}\n\n.gpc-field input:focus {\n\toutline: none;\n\tborder-color: var(--gpc-primary);\n\tbox-shadow: 0 0 0 3px rgba(245,166,35,0.18);\n}\n\n.gpc-conditional-input {\n\tmargin-top: 10px;\n\tborder: 1.5px solid var(--gpc-border);\n\tborder-radius: 10px;\n\tpadding: 11px 14px;\n\tfont-size: 14px;\n\twidth: 100%;\n\tfont-family: inherit;\n}\n\n\/* ---------- Radios & Checkboxes ---------- *\/\n.gpc-radio-group {\n\tdisplay: flex;\n\tflex-direction: column;\n\tgap: 10px;\n\tmargin-top: 4px;\n}\n\n.gpc-radio, .gpc-checkbox {\n\tdisplay: flex;\n\talign-items: flex-start;\n\tgap: 10px;\n\tfont-size: 13.5px;\n\tcursor: pointer;\n\tbackground: var(--gpc-bg);\n\tborder: 1.5px solid var(--gpc-border);\n\tborder-radius: 10px;\n\tpadding: 12px 14px;\n\ttransition: border-color .15s ease, background .15s ease;\n}\n\n.gpc-radio:hover, .gpc-checkbox:hover {\n\tborder-color: var(--gpc-secondary);\n}\n\n.gpc-radio input, .gpc-checkbox input {\n\tmargin-top: 2px;\n\twidth: 18px;\n\theight: 18px;\n\taccent-color: var(--gpc-primary);\n\tflex-shrink: 0;\n}\n\n.gpc-checkbox {\n\tmargin-top: 14px;\n\tfont-weight: 600;\n}\n\n.gpc-radio:has(input:checked), .gpc-checkbox:has(input:checked) {\n\tborder-color: var(--gpc-primary);\n\tbackground: rgba(245,166,35,0.08);\n}\n\n\/* ---------- Signature ---------- *\/\n.gpc-signature-wrapper {\n\tposition: relative;\n\tborder: 2px dashed var(--gpc-gray);\n\tborder-radius: var(--gpc-radius);\n\tbackground: #fdfdfc;\n\toverflow: hidden;\n}\n\n.gpc-signature-pad {\n\twidth: 100%;\n\theight: 200px;\n\tdisplay: block;\n\ttouch-action: none;\n\tcursor: crosshair;\n\tbackground: #fff;\n}\n\n.gpc-btn-clear-signature {\n\tposition: absolute;\n\ttop: 10px;\n\tright: 10px;\n\tbackground: #fff;\n\tborder: 1.5px solid var(--gpc-border);\n\tcolor: var(--gpc-dark);\n\tfont-size: 12px;\n\tfont-weight: 600;\n\tpadding: 6px 12px;\n\tborder-radius: 8px;\n\tcursor: pointer;\n\ttransition: all .15s ease;\n}\n\n.gpc-btn-clear-signature:hover {\n\tborder-color: var(--gpc-primary);\n\tcolor: var(--gpc-primary-dark);\n}\n\n.gpc-signature-hint {\n\tfont-size: 12px;\n\tcolor: var(--gpc-gray);\n\tmargin: 8px 0 0;\n}\n\n\/* ---------- Submit ---------- *\/\n.gpc-submit-row {\n\tmargin-top: 30px;\n\ttext-align: center;\n}\n\n.gpc-submit-btn {\n\tbackground: linear-gradient(135deg, var(--gpc-primary), var(--gpc-primary-dark));\n\tcolor: #fff;\n\tborder: none;\n\tpadding: 16px 48px;\n\tfont-size: 16px;\n\tfont-weight: 700;\n\tborder-radius: 50px;\n\tcursor: pointer;\n\tbox-shadow: 0 6px 20px rgba(245,166,35,0.35);\n\ttransition: transform .15s ease, box-shadow .15s ease;\n\tdisplay: inline-flex;\n\talign-items: center;\n\tgap: 10px;\n}\n\n.gpc-submit-btn:hover {\n\ttransform: translateY(-2px);\n\tbox-shadow: 0 10px 26px rgba(245,166,35,0.45);\n}\n\n.gpc-submit-btn:disabled {\n\topacity: 0.7;\n\tcursor: not-allowed;\n\ttransform: none;\n}\n\n.gpc-btn-spinner {\n\twidth: 16px;\n\theight: 16px;\n\tborder: 2.5px solid rgba(255,255,255,0.5);\n\tborder-top-color: #fff;\n\tborder-radius: 50%;\n\tanimation: gpc-spin 0.8s linear infinite;\n}\n\n@keyframes gpc-spin {\n\tto { transform: rotate(360deg); }\n}\n\n.gpc-form-error {\n\tcolor: #b3261e;\n\tbackground: #fdecea;\n\tborder: 1px solid #f4c7c3;\n\tborder-radius: 10px;\n\tpadding: 12px 16px;\n\tfont-size: 13.5px;\n\tmargin-top: 16px;\n\ttext-align: left;\n}\n\n\/* ---------- Cambi\u00e9 de opini\u00f3n ---------- *\/\n.gpc-changed-mind-row {\n\tmargin-top: 26px;\n\tpadding-top: 22px;\n\tborder-top: 1px dashed var(--gpc-border);\n\ttext-align: center;\n}\n\n.gpc-changed-mind-divider {\n\tdisplay: block;\n\tfont-size: 13px;\n\tcolor: var(--gpc-gray);\n\tmargin-bottom: 10px;\n}\n\n.gpc-changed-mind-btn {\n\tbackground: #fff;\n\tcolor: var(--gpc-primary-dark);\n\tborder: 1.5px solid var(--gpc-secondary);\n\tpadding: 12px 26px;\n\tfont-size: 14px;\n\tfont-weight: 700;\n\tborder-radius: 50px;\n\tcursor: pointer;\n\ttransition: all .15s ease;\n}\n\n.gpc-changed-mind-btn:hover {\n\tbackground: rgba(245,166,35,0.08);\n\tborder-color: var(--gpc-primary);\n}\n\n.gpc-changed-mind-btn:disabled {\n\topacity: 0.7;\n\tcursor: not-allowed;\n}\n\n\/* ---------- Bloque de contacto ---------- *\/\n.gpc-contact-block {\n\tbackground: linear-gradient(135deg, var(--gpc-dark) 0%, #3a3533 100%);\n\tpadding: 34px 36px 38px;\n\ttext-align: center;\n}\n\n.gpc-contact-title {\n\tcolor: var(--gpc-secondary);\n\tfont-size: 20px;\n\tfont-weight: 800;\n\tletter-spacing: 0.5px;\n\tmargin: 0 0 20px;\n}\n\n.gpc-contact-list {\n\tlist-style: none;\n\tmargin: 0 auto;\n\tpadding: 0;\n\tmax-width: 480px;\n\tdisplay: flex;\n\tflex-direction: column;\n\tgap: 12px;\n\ttext-align: left;\n}\n\n.gpc-contact-list li {\n\tdisplay: flex;\n\talign-items: center;\n\tgap: 10px;\n\tcolor: #f2efe9;\n\tfont-size: 14px;\n}\n\n.gpc-contact-icon {\n\tflex-shrink: 0;\n\tfont-size: 16px;\n}\n\n.gpc-contact-list a {\n\tcolor: var(--gpc-secondary);\n\ttext-decoration: none;\n\tfont-weight: 600;\n\tborder-bottom: 1px solid rgba(247,200,115,0.4);\n}\n\n.gpc-contact-list a:hover {\n\tcolor: var(--gpc-primary);\n\tborder-bottom-color: var(--gpc-primary);\n}\n\n\/* ---------- Confirmation ---------- *\/\n.gpc-confirmation {\n\ttext-align: center;\n\tpadding: 70px 40px 80px;\n}\n\n.gpc-confirmation-icon {\n\twidth: 84px;\n\theight: 84px;\n\tborder-radius: 50%;\n\tbackground: linear-gradient(135deg, var(--gpc-primary), var(--gpc-secondary));\n\tcolor: #fff;\n\tfont-size: 40px;\n\tdisplay: flex;\n\talign-items: center;\n\tjustify-content: center;\n\tmargin: 0 auto 24px;\n\tbox-shadow: 0 8px 24px rgba(245,166,35,0.35);\n}\n\n.gpc-confirmation-title {\n\tfont-size: 24px;\n\tfont-weight: 800;\n\tmargin: 0 0 12px;\n\tcolor: var(--gpc-dark);\n}\n\n.gpc-confirmation-text {\n\tfont-size: 15px;\n\tcolor: #55504e;\n\tmax-width: 480px;\n\tmargin: 0 auto;\n}\n\n\/* ---------- Responsive ---------- *\/\n@media (max-width: 640px) {\n\t.gpc-form-wrapper {\n\t\tmargin: 12px auto;\n\t}\n\t.gpc-form-header {\n\t\tpadding: 30px 20px 24px;\n\t}\n\t.gpc-form-title {\n\t\tfont-size: 18px;\n\t}\n\t.gpc-form {\n\t\tpadding: 6px 18px 26px;\n\t}\n\t.gpc-grid {\n\t\tgrid-template-columns: 1fr;\n\t}\n\t.gpc-submit-btn {\n\t\twidth: 100%;\n\t\tjustify-content: center;\n\t}\n\t.gpc-signature-pad {\n\t\theight: 160px;\n\t}\n\t.gpc-confirmation {\n\t\tpadding: 50px 20px 60px;\n\t}\n\t.gpc-contact-block {\n\t\tpadding: 28px 20px 32px;\n\t}\n\t.gpc-contact-list li {\n\t\tfont-size: 13.5px;\n\t}\n}\n\t\t\t\t:root{--gpc-primary:#F5A623;--gpc-primary-dark:#D98812;--gpc-secondary:#F7C873;--gpc-gray:#8A8D8F;--gpc-dark:#231F20;}\n\t\t\t<\/style>\n\t\t\t\t<div class=\"gpc-form-wrapper\" id=\"gpc-nwcdIp\">\n\n\t\t\t<div class=\"gpc-form-card\">\n\n\t\t\t\t<div class=\"gpc-form-header\">\n\t\t\t\t\t\t\t\t\t\t\t<img decoding=\"async\" src=\"https:\/\/sierraplanchoice.com\/wp-content\/uploads\/2026\/08\/e56552_6532f9ba710944b68ba623ae123128f3mv2-270x300.png\" alt=\"Golden Plan Choice - G.P.C.A. Inc.\" class=\"gpc-logo\">\n\t\t\t\t\t\t\t\t\t\t<p class=\"gpc-agency-contact\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/p>\n\t\t\t\t\t<h1 class=\"gpc-form-title\">Solicitud de Cancelaci\u00f3n de Cobertura M\u00e9dica y Descargo de Responsabilidad<\/h1>\n\t\t\t\t\t<p class=\"gpc-form-subtitle\">Documento conforme a los lineamientos de CMS y el Marketplace de Salud<\/p>\n\t\t\t\t<\/div>\n\n\t\t\t\t<form id=\"gpc-cancel-form\" class=\"gpc-form\" novalidate>\n\t\t\t\t\t<input type=\"hidden\" id=\"gpc_nonce_field\" name=\"gpc_nonce_field\" value=\"33d3f896cf\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/es\/wp-json\/wp\/v2\/pages\/3322\" \/>\n\t\t\t\t\t<!-- SECCI\u00d3N 1 -->\n\t\t\t\t\t<div class=\"gpc-section\">\n\t\t\t\t\t\t<h3 class=\"gpc-section-title\"><span class=\"gpc-badge\">1<\/span> Datos del Titular \/ Asegurado Principal<\/h3>\n\t\t\t\t\t\t<div class=\"gpc-grid\">\n\t\t\t\t\t\t\t<div class=\"gpc-field gpc-col-2\">\n\t\t\t\t\t\t\t\t<label>Nombre Completo *<\/label>\n\t\t\t\t\t\t\t\t<input type=\"text\" name=\"nombre_completo\" required>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"gpc-field\">\n\t\t\t\t\t\t\t\t<label>Fecha de Nacimiento *<\/label>\n\t\t\t\t\t\t\t\t<input type=\"date\" name=\"fecha_nacimiento\" required>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"gpc-field\">\n\t\t\t\t\t\t\t\t<label>Tel\u00e9fono *<\/label>\n\t\t\t\t\t\t\t\t<input type=\"tel\" name=\"telefono\" required>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"gpc-field\">\n\t\t\t\t\t\t\t\t<label>Correo Electr\u00f3nico *<\/label>\n\t\t\t\t\t\t\t\t<input type=\"email\" name=\"correo\" required>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"gpc-field gpc-col-2\">\n\t\t\t\t\t\t\t\t<label>Compa\u00f1\u00eda de Seguros *<\/label>\n\t\t\t\t\t\t\t\t<input type=\"text\" name=\"compania_seguros\" required>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- SECCI\u00d3N 2 -->\n\t\t\t\t\t<div class=\"gpc-section\">\n\t\t\t\t\t\t<h3 class=\"gpc-section-title\"><span class=\"gpc-badge\">2<\/span> Solicitud de Cancelaci\u00f3n y Fecha Efectiva<\/h3>\n\t\t\t\t\t\t<p class=\"gpc-legal-text\">Por la presente, solicito formalmente la cancelaci\u00f3n de mi p\u00f3liza de seguro m\u00e9dico y autorizo expresamente a mi agente licenciado y a la agencia a realizar los tr\u00e1mites pertinentes ante la aseguradora y\/o el Marketplace.<\/p>\n\t\t\t\t\t\t<div class=\"gpc-grid\">\n\t\t\t\t\t\t\t<div class=\"gpc-field gpc-col-2\">\n\t\t\t\t\t\t\t\t<label>Fecha Efectiva de Cancelaci\u00f3n (\u00daltimo d\u00eda de cobertura) *<\/label>\n\t\t\t\t\t\t\t\t<input type=\"date\" name=\"fecha_efectiva\" required>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- SECCI\u00d3N 3 -->\n\t\t\t\t\t<div class=\"gpc-section\">\n\t\t\t\t\t\t<h3 class=\"gpc-section-title\"><span class=\"gpc-badge\">3<\/span> Motivo y Declaraci\u00f3n de Asesor\u00eda Previa<\/h3>\n\n\t\t\t\t\t\t<div class=\"gpc-field\">\n\t\t\t\t\t\t\t<label>Raz\u00f3n principal de la cancelaci\u00f3n *<\/label>\n\t\t\t\t\t\t\t<div class=\"gpc-radio-group\">\n\t\t\t\t\t\t\t\t<label class=\"gpc-radio\"><input type=\"radio\" name=\"razon_cancelacion\" value=\"Cobertura obtenida a trav\u00e9s de un empleo (Seguro de Grupo Elegible)\" required><span>Cobertura obtenida a trav\u00e9s de un empleo (Seguro de Grupo Elegible)<\/span><\/label>\n\t\t\t\t\t\t\t\t<label class=\"gpc-radio\"><input type=\"radio\" name=\"razon_cancelacion\" value=\"Cambio de residencia o elegibilidad a otros programas (Medicare \/ Medicaid)\" required><span>Cambio de residencia o elegibilidad a otros programas (Medicare \/ Medicaid)<\/span><\/label>\n\t\t\t\t\t\t\t\t<label class=\"gpc-radio\"><input type=\"radio\" name=\"razon_cancelacion\" value=\"Otra\" required><span>Otra raz\u00f3n:<\/span><\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<input type=\"text\" name=\"razon_otra\" class=\"gpc-conditional-input\" placeholder=\"Especifique la otra raz\u00f3n\">\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"gpc-field\">\n\t\t\t\t\t\t\t<label>Reconocimiento de Asesor\u00eda de Comparaci\u00f3n *<\/label>\n\t\t\t\t\t\t\t<p class=\"gpc-legal-text\">Certifico que mi agente me explic\u00f3 las implicaciones de cancelar mi plan actual y me ofreci\u00f3 revisar la comparaci\u00f3n de beneficios (primas, deducibles, copagos, red de doctores, coaseguro, m\u00e1ximo de bolsillo y cobertura de medicamentos prescritos).<\/p>\n\t\t\t\t\t\t\t<div class=\"gpc-radio-group\">\n\t\t\t\t\t\t\t\t<label class=\"gpc-radio\"><input type=\"radio\" name=\"decision_asegurado\" value=\"Recib\u00ed la comparaci\u00f3n de beneficios y confirmo mi decisi\u00f3n de cancelar.\" required><span>Recib\u00ed la comparaci\u00f3n de beneficios y confirmo mi decisi\u00f3n de cancelar.<\/span><\/label>\n\t\t\t\t\t\t\t\t<label class=\"gpc-radio\"><input type=\"radio\" name=\"decision_asegurado\" value=\"Declin\u00e9 la comparaci\u00f3n de beneficios ofrecida por el agente y solicito la cancelaci\u00f3n directa.\" required><span>Declin\u00e9 la comparaci\u00f3n de beneficios ofrecida por el agente y solicito la cancelaci\u00f3n directa.<\/span><\/label>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- SECCI\u00d3N 4 -->\n\t\t\t\t\t<div class=\"gpc-section\">\n\t\t\t\t\t\t<h3 class=\"gpc-section-title\"><span class=\"gpc-badge\">4<\/span> Reconocimiento de Riesgos y Divulgaci\u00f3n Obligatoria de CMS<\/h3>\n\t\t\t\t\t\t<ul class=\"gpc-legal-list\">\n\t\t\t\t\t\t\t<li><strong>P\u00e9rdida de Cobertura y Per\u00edodos de Inscripci\u00f3n:<\/strong> Entiendo que al cancelar mi p\u00f3liza, quedar\u00e9 sin cobertura m\u00e9dica a partir de la fecha efectiva. Comprendo que solo podr\u00e9 volver a inscribirme en un plan de salud durante el Per\u00edodo de Inscripci\u00f3n Abierta (Open Enrollment) o si califico para un Per\u00edodo Especial de Inscripci\u00f3n (SEP) seg\u00fan las reglas de CMS.<\/li>\n\t\t\t\t\t\t\t<li><strong>Exclusi\u00f3n de Cobertura Posterior:<\/strong> Comprendo que cualquier servicio m\u00e9dico, emergencia, cirug\u00eda, hospitalizaci\u00f3n o medicamento recetado que ocurra a partir de la fecha de cancelaci\u00f3n no estar\u00e1 cubierto, asumiendo la totalidad de los costos m\u00e9dicos bajo mi propia responsabilidad.<\/li>\n\t\t\t\t\t\t\t<li><strong>Liberaci\u00f3n de Responsabilidad:<\/strong> Exonero a mi agente y a la agencia de cualquier responsabilidad civil, legal o financiera derivada de la interrupci\u00f3n de mi cobertura m\u00e9dica por solicitud propia.<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<label class=\"gpc-checkbox\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" name=\"acepta_riesgos\" required>\n\t\t\t\t\t\t\t<span>He le\u00eddo y entiendo los riesgos y la divulgaci\u00f3n obligatoria de CMS descritos anteriormente. *<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- SECCI\u00d3N 5 -->\n\t\t\t\t\t<div class=\"gpc-section\">\n\t\t\t\t\t\t<h3 class=\"gpc-section-title\"><span class=\"gpc-badge\">5<\/span> Protecci\u00f3n de Datos (HIPAA \/ PII) y Aviso de No Discriminaci\u00f3n<\/h3>\n\t\t\t\t\t\t<p class=\"gpc-legal-text\"><strong>Privacidad de la Informaci\u00f3n (HIPAA \/ PII):<\/strong> La informaci\u00f3n proporcionada en este formulario ser\u00e1 utilizada \u00fanicamente con el prop\u00f3sito de procesar su cancelaci\u00f3n y mantener los registros requeridos por las agencias reguladoras federales. Su Informaci\u00f3n de Identificaci\u00f3n Personal (PII) est\u00e1 protegida bajo los est\u00e1ndares de privacidad vigentes.<\/p>\n\t\t\t\t\t\t<p class=\"gpc-legal-text\"><strong>Aviso de No Discriminaci\u00f3n (Secci\u00f3n 1557 de la ACA):<\/strong> Nuestra agencia cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.<\/p>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- SECCI\u00d3N 6 -->\n\t\t\t\t\t<div class=\"gpc-section gpc-section-highlight\">\n\t\t\t\t\t\t<h3 class=\"gpc-section-title\"><span class=\"gpc-badge\">6<\/span> Informaci\u00f3n de Contacto de la Agencia y Servicios<\/h3>\n\t\t\t\t\t\t<p class=\"gpc-legal-text\">Le recordamos que nuestra agencia es <strong>100% independiente<\/strong> y cuenta con <strong>todas las compa\u00f1\u00edas de seguros<\/strong> del mercado. Nuestra asesor\u00eda es completamente gratuita \u2014 no cobramos por el servicio \u2014 y ayudamos a personas <strong>con o sin estatus migratorio<\/strong>. En el futuro, podemos asistirlo en:<\/p>\n\t\t\t\t\t\t<ul class=\"gpc-services-list\">\n\t\t\t\t\t\t\t<li>Medicare Advantage y Medicare Suplementario<\/li>\n\t\t\t\t\t\t\t<li>Medicare Parte D (Medicamentos)<\/li>\n\t\t\t\t\t\t\t<li>Salud con ACA \/ Obamacare<\/li>\n\t\t\t\t\t\t\t<li>Planes dentales y de visi\u00f3n<\/li>\n\t\t\t\t\t\t\t<li>Planes suplementarios por accidente, c\u00e1ncer y enfermedades cr\u00edticas<\/li>\n\t\t\t\t\t\t\t<li>Planes funerarios<\/li>\n\t\t\t\t\t\t\t<li>Seguros de vida<\/li>\n\t\t\t\t\t\t\t<li>Anualidades (Inversiones Seguras)<\/li>\n\t\t\t\t\t\t\t<li>Seguros para empresas<\/li>\n\t\t\t\t\t\t\t<li>Seguro de viajes<\/li>\n\t\t\t\t\t\t\t<li>Seguros m\u00e9dicos internacionales, vida e inversiones<\/li>\n\t\t\t\t\t\t\t<li>Seguro m\u00e9dico privado<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<!-- SECCI\u00d3N 7 -->\n\t\t\t\t\t<div class=\"gpc-section\">\n\t\t\t\t\t\t<h3 class=\"gpc-section-title\"><span class=\"gpc-badge\">7<\/span> Firma y Consentimiento Informado del Cliente<\/h3>\n\t\t\t\t\t\t<p class=\"gpc-legal-text\">Al firmar a continuaci\u00f3n, confirmo que soy el titular de la p\u00f3liza o el representante legal autorizado, que he le\u00eddo y comprendido los t\u00e9rminos descritos y que autorizo de forma voluntaria la cancelaci\u00f3n solicitada.<\/p>\n\n\t\t\t\t\t\t<div class=\"gpc-grid\">\n\t\t\t\t\t\t\t<div class=\"gpc-field gpc-col-2\">\n\t\t\t\t\t\t\t\t<label>Nombre del Cliente \/ Asegurado Principal (para la firma) *<\/label>\n\t\t\t\t\t\t\t\t<input type=\"text\" name=\"nombre_firma\" required>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<div class=\"gpc-field\">\n\t\t\t\t\t\t\t<label>Firma Digital *<\/label>\n\t\t\t\t\t\t\t<div class=\"gpc-signature-wrapper\">\n\t\t\t\t\t\t\t\t<canvas id=\"gpc-signature-pad-gpc-nwcdIp\" class=\"gpc-signature-pad\" width=\"600\" height=\"200\"><\/canvas>\n\t\t\t\t\t\t\t\t<button type=\"button\" class=\"gpc-btn-clear-signature\" data-target=\"gpc-signature-pad-gpc-nwcdIp\">Borrar Firma<\/button>\n\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<input type=\"hidden\" name=\"firma_base64\" class=\"gpc-signature-data\">\n\t\t\t\t\t\t\t<p class=\"gpc-signature-hint\">Firme dentro del recuadro usando el mouse o el dedo (en pantalla t\u00e1ctil).<\/p>\n\t\t\t\t\t\t<\/div>\n\n\t\t\t\t\t\t<label class=\"gpc-checkbox\">\n\t\t\t\t\t\t\t<input type=\"checkbox\" name=\"acepta_consentimiento\" required>\n\t\t\t\t\t\t\t<span>Confirmo que soy el titular de la p\u00f3liza o representante legal autorizado y autorizo voluntariamente esta cancelaci\u00f3n. *<\/span>\n\t\t\t\t\t\t<\/label>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div class=\"gpc-submit-row\">\n\t\t\t\t\t\t<button type=\"submit\" class=\"gpc-submit-btn\">\n\t\t\t\t\t\t\t<span class=\"gpc-btn-text\">Enviar Solicitud<\/span>\n\t\t\t\t\t\t\t<span class=\"gpc-btn-spinner\" style=\"display:none;\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t\t\t\t<p class=\"gpc-form-error\" style=\"display:none;\"><\/p>\n\n\t\t\t\t\t\t<div class=\"gpc-changed-mind-row\">\n\t\t\t\t\t\t\t<span class=\"gpc-changed-mind-divider\">\u00bfYa no desea cancelar su p\u00f3liza?<\/span>\n\t\t\t\t\t\t\t<button type=\"button\" class=\"gpc-changed-mind-btn\">Cambi\u00e9 de opini\u00f3n, deseo continuar con mi plan<\/button>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/form>\n\n\t\t\t\t<div class=\"gpc-confirmation\" style=\"display:none;\">\n\t\t\t\t\t<div class=\"gpc-confirmation-icon\">\u2713<\/div>\n\t\t\t\t\t<h2 class=\"gpc-confirmation-title\"><\/h2>\n\t\t\t\t\t<p class=\"gpc-confirmation-text\"><\/p>\n\t\t\t\t<\/div>\n\n\t\t\t\t<div class=\"gpc-confirmation gpc-changed-mind-confirmation\" style=\"display:none;\">\n\t\t\t\t\t<div class=\"gpc-confirmation-icon\">\ud83d\udc9b<\/div>\n\t\t\t\t\t<h2 class=\"gpc-confirmation-title\">\u00a1Gracias por continuar con nosotros!<\/h2>\n\t\t\t\t\t<p class=\"gpc-confirmation-text\">Nos alegra que siga confiando en Golden Plan Choice. Su cobertura actual permanece activa y sin cambios. Si en alg\u00fan momento tiene preguntas o necesita ayuda, estamos aqu\u00ed para usted.<\/p>\n\t\t\t\t<\/div>\n\n\t\t\t\t<div class=\"gpc-contact-block\">\n\t\t\t\t\t<h3 class=\"gpc-contact-title\">\u00a1CONT\u00c1CTENOS!<\/h3>\n\t\t\t\t\t<ul class=\"gpc-contact-list\">\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<span class=\"gpc-contact-icon\">\u260e\ufe0f<\/span>\n\t\t\t\t\t\t\t<span>OFICINA <a href=\"tel:+13464741947\">(346) 474-1947<\/a><\/span>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<span class=\"gpc-contact-icon\">\ud83d\udccd<\/span>\n\t\t\t\t\t\t\t<span>12001 Richmond Ave. Ste 6, Houston, TX 77082 \u2014\n\t\t\t\t\t\t\t\t<a href=\"https:\/\/maps.app.goo.gl\/fwPFthCHxkcqeuxG7?g_st=ic\" target=\"_blank\" rel=\"noopener noreferrer\">C\u00f3mo llegar<\/a>\n\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<span class=\"gpc-contact-icon\">\ud83c\udf10<\/span>\n\t\t\t\t\t\t\t<span><a href=\"https:\/\/www.goldenplanchoice.com\" target=\"_blank\" rel=\"noopener noreferrer\">www.goldenplanchoice.com<\/a><\/span>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<span class=\"gpc-contact-icon\">\ud83c\udf10<\/span>\n\t\t\t\t\t\t\t<span><a href=\"https:\/\/www.sierraplanchoice.com\" target=\"_blank\" rel=\"noopener noreferrer\">www.sierraplanchoice.com<\/a> (cotizar \/ enrolar)<\/span>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<span class=\"gpc-contact-icon\">\u2709\ufe0f<\/span>\n\t\t\t\t\t\t\t<span><a href=\"mailto:danielsb@sierraplanchoice.com\">danielsb@sierraplanchoice.com<\/a><\/span>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<li>\n\t\t\t\t\t\t\t<span class=\"gpc-contact-icon\">\ud83d\udcf1<\/span>\n\t\t\t\t\t\t\t<span>Cell <a href=\"tel:+17135912747\">(713) 591-2747<\/a><\/span>\n\t\t\t\t\t\t<\/li>\n\t\t\t\t\t<\/ul>\n\t\t\t\t<\/div>\n\n\t\t\t<\/div>\n\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_canvas","meta":{"_monsterinsights_skip_tracking":false,"_kadence_starter_templates_imported_post":false,"_kad_post_transparent":"","_kad_post_title":"hide","_kad_post_layout":"fullwidth","_kad_post_sidebar_id":"","_kad_post_content_style":"unboxed","_kad_post_vertical_padding":"hide","_kad_post_feature":"hide","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"_kad_post_classname":"","_joinchat":[],"footnotes":""},"class_list":["post-3322","page","type-page","status-publish","hentry"],"aioseo_notices":[],"aioseo_head":"\n\t\t<!-- All in One SEO 5.0.1.1 - 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