MEDICARE INFO & SOA FORM MASTER

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 NameMiddle Name or Initial Last Name

Are You An Authorized Representative? If YES, click & fill in. If NO, leave blank.
Authorized Representative Name

First NameLast 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)

MonthDayYear
Date
Medical (Part B) Date (On your Medicare card - Example Above )

MonthDayYear
Date
Current Medicare Health Insurance Plan Name ( If on one )
Example: AARP Medicare Advantage Walgreens (PPO)

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

CityState / Province

Postal / Zip Code

Your Home County*
What County do you live in? Example: Orange County
Date Of Birth*

MonthDayYear
Date
Prescription Drug(s) (Example: Drug Name: Metformin | Dosage: 10 mg | Quantity Per Month : 30)
Best Phone Number*
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)*

Stand-alone Medicare Prescription Drug Plans (Part D)Medicare Advantage Plans (Part C) and Cost PlansDental/Vision/Hearing ProductsHospital Indemnity ProductsMedicare Supplement (Medigap) Products
Signature | Please type your full name*
Beneficiary Or Authorized Representative
Date*

MonthDayYear
Today Date | Appointment Date
Should be Empty:

MEDICARE INFO