Pre-Appointment Provider and Medication Survey

In preparation for your scheduled appointment, your agent can do some preliminary research on which plans most closely match your current needs. 

Complete and submit the form below to send your agent information about your primary care and specialist providers and, if selected, a list of  medications currently prescribed and filled through a pharmacy. 

Provider Medication and Pharmacy Worksheet
We will send confirmation to this email. Please check inbox or spam folder.
My agent (please select one): *
Your provider, prescription drug and pharmacy information will be sent to your agent. This helps your agent be prepared for your telephone, in person or Zoom appointment.
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Provided in case your agent has questions before your scheduled appointment.
Some Medicare health plans are available only in specific areas, please provide the county and state. Ex: Albany County, NY
Your agent can confirm which plan(s) your primary care provider (MD, PA or FNP) or medical group is currently "in-network" with.
Please provide the specialty, provider name and location. Your agent will confirm which plan(s) your specialist provider(s) are currently "in-network" with.
PART B and PART D Medications
If you are currently taking Part B medications administered through a healthcare setting, be sure to ask your agent about staying with Original Medicare and adding a Medicare Supplement plan to cover the 20% share with the Part B medications.
Are there any brand name Part D medications you are currently taking that you would like your agent to look up for you?
Do you get help with your Medicare health or drug costs?
If you get help with your Medicare health or drug costs from one of the programs above, it's important for us to know so we can show you accurate cost information when we search for and compare plans.
My current pharmacy
Your agent will confirm which plan(s) consider your current pharmacy as "preferred."
This helps us compare your current Medicare plan to what you may change to. Type "new to Medicare" if applicable.