Medicare Worksheet 2024

Name *

First

Last

Address *

Address Line 1

City

State

Zip Code

Email *

Phone *

Date of Birth

Living with someone? *

Yes
No

Layout

Medicare Number *

Current Prescription Plan Name *

Current Prescription Plan Copay(s) *

Part A & B Effective Date *

Current Plan Monthly Premium *

Preferred Pharmacy *

Please include a local pharmacy even if you are currently using mail order

Prescriptions

Please list your current prescriptions below. If you are taking a generic, specify what drugs are generic.
To add an additional prescription please click the "Add Prescription" button.

Generic

Yes

Prescription Name *

Dosage

Number of Pills Per Day

Add Prescription

Doctors

List your current physicians and specialists below.

Doctor

Address

Address Line 1

City

State

Zip Code

Phone

End Repeater

Add Doctor

Scope of Appointment

The Scope of Appointment is required by compliance and confirms you gave permission for us to review the Medicare plans with you.

Scope of Appointment *

I have read and signed a Scope of Appointment (SOA) Form. Please click here to read and sign.