Provider and Medication Survey

If you would like for your agent to do some preliminary research on which coverage and plans most closely match your current needs, you can voluntarily submit some additional details via the form below.

Information about your primary care and specialist providers and, if selected, your medications currently prescribed will be sent to your agent via e-mail. You will receive a copy by email for your file. Your agent must comply with the Centers for Medicare & Medicaid Services (CMS) and HIPAA rules that require us to “handle physical and digital data safely.”  (Click for copy of Privacy Policy)

Again, providing your agent with any Protected Health Information (PHI) and/or Personal Identifiable Information (PII) is strictly voluntary. Even if you choose not to provide personal information at this time, your agent may still review with you plans available in your area.

Provider Medication and Pharmacy Worksheet
My Licensed Sales 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.
The following fields request personal information. Please check how you choose to proceed:
Also, by submitting the information below, I am agreeing to be contacted by my selected Licensed Sales Agent by email or phone call to discuss information about Medicare Insurance Plans. This is a solicitation for insurance. Medicare Permission to Contact (PTC) guidelines require agents to obtain explicit, documented consent from a beneficiary before initiating any unsolicited outreach. The PTC consent expires after 9 months.
We will send confirmation to this email. Please check inbox or spam folder.
1
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.
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. Please do NOT state the medical condition your specialist is treating. 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?
Please do NOT state the reason for taking the medication.
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.
Please confirm permission to proceed: