Agent Name
Agent Email
Agent Logo
Email Address
*
*
Not familiar
A little familiar, but I don't know where to start
I have a pretty good idea
First Name
*
Last Name
*
Date of birth
*
*
I'm already on Medicare
I have coverage through my employer/union
I have an individual plan through the marketplace
I'm on COBRA
I have Medicaid
I don't have health insurance
*
I'm not sure (and that's ok!)
Medicare Supplement + Prescription Drug Plan
Medicare Advantage
Just Medicare A + B
Address
*
Apt or Suite #
City
*
State
*
Postal code
*
County
*
Pharmacy 1
Pharmacy 2
Pharmacy 3
Prescription 1
Prescription 2
Prescription 3
Prescription 4
Prescription 5
Prescription 6
Prescription 7
Prescription 8
Prescription 9
Prescription 10
Additional Prescriptions?
*
Yes
No
Prescription 11
Prescription 12
Prescription 13
Prescription 14
Prescription 15
Prescription 16
Prescription 17
Prescription 18
Prescription 19
Prescription 20
Preferred Hospital
Who is your primary care physician?
Do you have any specialists?
Specialist 1
Specialist 2
Specialist 3
Specialist 4
Specialist 5
Do you see any additional physicians?
*
Yes
No
Additional Physicians?
Physicians 1
Physicians 2
Physicians 3
Physicians 4
Physicians 5
Physicians 6
Physicians 7
Who is your dentist?
Who is your Optometrist? (Vision Provider)
I don't mind paying copays for medical services in exchange for lower monthly premiums.
I would prefer to pay higher monthly premiums in exchange for little or no out-of-pocket costs for medical services.
Federal Retirement Benefits
State Retirement Benefits
State Teachers Retirement System
Tricare
VA (Veterans Affairs)
ChampVA
None of these apply
Phone
*
What's Your Age?
Signature
*
Clear