Medicare Plan Consultation Form
Thank you for taking time to complete this form. This provides us with the information we need to compare your current coverage with all plans available in your area. We will be in touch with you once we determine your best options. Please note: Plans for 2023 will be available to view starting October 1st. We will do our best to provide your plan analysis as soon as possible after that date. Enrollment runs from October 15 through December 7. If you enroll in a plan, the plan would take effect January 1st.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State
Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Do we have permission to contact you at this number about your Medicare?
Yes
No
Your Current Medicare Plan
Do you have both Medicare Part A and Part B?
Yes
No
Do you have any additional coverage, such as a supplement or Medicare Advantage plan?
Yes, I have a supplement
Yes, I have a Medicare Advantage plan
No, I only have Medicare A and B
If yes, is this coverage through retirement, employer, union, through a spouse, Tricare (military), or other group plan? Note: Berks Medicare only works with individual Medicare plans. If you have a plan through one of the sources above, please contact your benefits administrator for more information on your plan.
Yes
No
Not sure
What type of Medicare plan do you currently have?
Medicare Advantage HMO
Medicare Advantage PPO
Medicare Advantage HMO-POS
Medicare Advantage DSNP (for people with both Medicare and Medicaid)
Medicare Supplement Plan
What company is the carrier of your current plan?
Aetna
Capital Blue Cross
Cigna
Geisinger
Health Partners
Highmark
Humana
United Healthcare
UPMC
Other
Do you have prescription drug coverage?
Yes
No
Not sure
What company is the carrier of your prescription drug plan?
Aetna
Capital Blue Cross
Cigna
Geisinger
Health Partners
Highmark
Humana
United Healthcare
UPMC
Other
Your Doctors
Your doctors are the most important part of your health care. What is the name of your primary care doctor?
Primary Care Doctor
Please provide the names of any specialists you see.
Specialist's Name
Specialty (cardiologist, opthomologist, etc.)
Specialist's Name
Specialty (cardiologist, opthomologist, etc.)
Specialist's Name
Specialty (cardiologist, opthomologist, etc.)
Specialist's Name
Specialty (cardiologist, opthomologist, etc.)
Specialist's Name
Specialty (cardiologist, opthomologist, etc.)
Specialist's Name
Specialty (cardiologist, opthomologist, etc.)
What is your preference of hospitals?
Reading Hospital-Tower Health
Penn State Health St. Joseph Medical Center
Other
Your Prescriptions
Prescription medication costs can vary greatly from plan to plan. Would you like us to include them in our plan research? (Do not include over the counter medications like aspirin, tylenol, vitamins, etc.)
Yes
No
What pharmacy do you use?
How would you prefer to do your free plan consultation?
In person
By email with follow up call
What type of plan/plans are you interested in? Choose all that apply.
Medicare Advantage
Medicare Supplement
Prescription Drug Plan
Stand alone dental and vision plan
Do you receive financial assistance from the government for your Medicare or prescription drug costs? Check any that apply.
Medicaid
Medicare Savings Program
Extra Help (LIS)
PACE
None
Not sure
Select the extra benefits that you would like with your plan.
Over the counter allowance
Dental
Vision
Hearing
Transportation to doctor appointments
Fitness benefit
Telehealth
In home support
Home safety devices
Emergency response device
Money back on Part B premium
Please provide any additional information you would like to share.
By submitting this form, you are requesting Berks Medicare do a plan analysis and share the results with you. There is no charge or obligation. We will not share your information.
Print Form
Save and finish later
Submit
Should be Empty: