Medicare Coverage

CHOOSING THE RIGHT MEDICARE COVERAGE

Choosing the right Medicare Coverage is an important decision. It’s not a “one size fits all” situation because everyone has different needs and budgets.

To assist you, we have designed a Personal Information Sheet for you to complete. This information, coupled with the answers to your questions, will help determine the right type of Medicare Coverage, benefits, out-of-pocket expense and cost to meet your personal health care needs and budget.

MEMBER INFORMATION

Referrer

Name*

First Name

Last Name

Date of Birth*

Phone Number*

Email*

Medicare Claim #*

Part A Effective Date*

Part B Effective Date*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Prescription List

Name of your preferred pharmacy*

If not just enter None

Do you take any prescriptions?*

Yes No

How many prescriptions do you take?*

#1 Medication Name*

#1 Dosage*

#1 Quantity*

#1 Day Supply*

#1 Mail Order/Retail*

#2 Medication Name*

#2 Dosage*

#2 Quantity*

#2 Day Supply*

#2 Mail Order/Retail*

#3 Medication Name *

#3 Dosage*

#3 Quantity*

#3 Day Supply*

#3 Mail Order/Retail*

#4 Medication Name*

#4 Dosage*

#4 Quantity*

#4 Day Supply*

#4 Mail Order/Retail*

#5 Medication Name *

#5 Dosage*

#5 Quantity*

#5 Mail Order/Retail*

#5 Day Supply*

#6 Medication Name*

#6 Dosage*

#6 Quantity*

#6 Day Supply*

#6 Mail Order/Retail*

Doctor List

Are you currently seeing any doctors?*

Yes No

How many different doctors are you seeing?*

#1 Doctor Name*

#1 Zip Code*

#1 Phone*

#1 Specialty*

#2 Doctor Name*

#2 Zip Code*

#2 Phone*

#2 Specialty*

#3 Doctor Name*

#3 Zip Code*

#3 Phone*

#3 Specialty*

#4 Doctor Name*

#4 Zip Code*

#4 Phone*

#4 Specialty*

#5 Doctor Name*

#5 Zip Code*

#5 Phone*

#5 Specialty*

#6 Doctor Name*

#6 Zip Code*

#6 Phone*

#6 Specialty*

Hospital List

Have you had hospital visit(s)?*

Yes No

How many different hospitals?*

#1 Hospital Name*

#1 Zip Code*

#1 Phone Number*

#2 Hospital Name*

#2 Zip Code*

#2 Phone Number*

#3 Hospital Name*

#3 Zip Code*

#3 Phone Number*

#4 Hospital Name*

#4 Zip Code*

#4 Phone Number*

#5 Hospital Name*

#5 Zip Code*

#5 Phone Number*

#6 Hospital Name*

#6 Zip Code*

#6 Phone Number*