Medicare Info

Please complete the information below that will assist us in helping you with your medicare needs. All information will be kept confidential.

MEDICARE PLANNER

* Indicates required field

First Name *

Last Name *

Date of Birth *

Street Address *

City, State, Zip *

County *

Are you married? (If yes, each person will need to complete their own form) *

Yes No

Medicare Number *

Part A Effective Date *

Part B Effective Date *

Email *

Phone Number *

Current Coverage *

Medicare Supplement Prescription Drug (Part D) Medicare Advantage Group/Individual

Medicare Supplement Carrier *

Medicare Supplement Plan (Plan A, F, G, etc) *

Medicare Supplement Premium *

Prescription Drug Plan Company *

Prescription Drug Plan Premium *

Medicare Advantage Plan Carrier *

Medicare Advantage Plan Premium *

Group Plan Company (If still employed & covered under a group health plan) *

Group Plan Premium *

Do you have a MyMedicare.gov account ? *

No - I don't have one. Please assist me in creating one (please provide mother's maiden name for set up) Yes - I have one (if yes, please provide your username, password, and mother's maiden name)

MyMedicare.gov username *

MyMedicare.gove password *

Mother's Maiden Name *

Preferred Pharmacy Location and Phone Number *

Second Choice Pharmacy Location and Phone Number *

Please list your current PRESCRIPTION MEDICATIONS along with the dosage and amount taken per day. One Rx per line please. (Example: Lisinopril, 20 mg, twice a day, No)

Medication *

Dosage *

Amount per day *

Generic (Yes or No?) *

Medication *

Dosage *

Amount per day *

Generic (Yes or No? *

Medication *

Dosage *

Amount per day *

Generic (Yes or No? *

Medication *

Dosage *

Amount per day *

Generic (Yes or No? *

Medication *

Dosage *

Amount per day *

Generic (Yes or No? *

Medication *

Dosage *

Amount per day *

Generic (Yes or No? *

Medication *

Dosage *

Amount per day *

Generic (Yes or No? *

Primary Care Physician and Phone Number *

Please list any specialist (name & specialty) you see in addition to your PCP. *

Please let us know any other questions or information you think we may need to know. *

Submit

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or
1-800-MEDICARE to get information on all of your options.