MEDICARE INFO
Please fill out all the boxes & submit to complete. Thank you! - Reese & Hailee Phillips
Name as it appears on your/their Medicare Card (Red, White, and Blue Card - Example Above)
*
First Name
Middle Name or Initial
Last Name
Are You An Authorized Representative? If YES, click & fill in. If NO, leave blank.
Authorized Representative Name
First Name
Last Name
Relationship To The Beneficiary
Example: Power Of Attorney, Son
MEDICARE Number (On your Red, White & Blue Medicare Card - Example Above)
Hospital (Part A) Date (On your Medicare card - Example Above)
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical (Part B) Date (On your Medicare card - Example Above )
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Medicare Health Insurance Plan Name ( If on one )
Example: AARP Medicare Advantage Walgreens (PPO)
Are you on State Medicaid? If YES, click & fill in. If NO, leave blank.
State Medicaid Card Number
Physical Address
*
Street Address
Apt or Unit number
City
State
Postal / Zip Code
Do you have a different mailing address? If YES, click & fill in. If NO, leave blank.
Mailing Address | If applicable, fill in. If not, leave blank.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Home County
*
What County do you live in? Example: Orange County
Date Of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Prescription Drug(s) (Example: Drug Name: Metformin | Dosage: 10 mg | Quantity Per Month : 30)
Best Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Doctor(s) Name & City (Example: Dr. Jon Smith New York City NY)
Scope of Appointment
Digital Signature for Scope of Appointment (Must Read Entire Disclaimer Before Clicking)
*
Please check the type of product(s) you want the agent to discuss. (Refer below for product type descriptions link)
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Stand-alone Medicare Prescription Drug Plans (Part D)
Medicare Advantage Plans (Part C) and Cost Plans
Dental/Vision/Hearing Products
Hospital Indemnity Products
Medicare Supplement (Medigap) Products
Signature | Please type your full name
*
Beneficiary Or Authorized Representative
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Today Date | Appointment Date
Submit
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