Request for Review

Request for Review

We will use this information to compare insurance plans and provide the results in our upcoming meeting.
Would you like a telephone or in office appointment?*

TELEPHONEIN-OFFICE
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Birth Date*

MonthDayYear
Zip Code*
County*
E-Mail
example@example.com
Primary Care Physician
First and Last Name
Specialist (Including all other doctors you see)
First and Last Names
Dentist
First and Last Name
Eye Doctor
First and Last Name
Preferred Hospital(s)*
Please list all hospitals you prefer to use or are currently using
Pharmacy you are currently using*
If you are currently using mail order please list mail order company and local pharmacy
Would you like to check prices at other pharmacies?
Would you like to use mail order?
Please rate your current Health Insurance Plan 1-10
1 - strongly dislike; 10 - strongly like
Are you taking any Prescription Medications?*

NOYES (Please enter all prescriptions in the next section)

Current Prescription Medications

	Prescription	Tablet Capsule Ointment Fluid	Dosage (mg)	How many do you take per day?	30 or 90 day supply?	Notes
1
2
3
4
5
6
7
8
9
10
11
12
13
14

*** If you are receiving assistance with these medications, using Good Rx, or purchasing from a Canadian Pharmacy, please tell us in the notes column.
Comments
Let us know of any upcoming procedures or just general comments or questions.
Broker you are scheduled with
Disclaimer: The Stonum Agency, Inc. will not sell, license, transmit or disclose this information outside of the Company unless (a) expressly authorized by you, (b) necessary to enable the Company's agents to perform certain functions for us, or (c) required or permitted by law. In all cases, we will disclose the information consistent with applicable laws and regulations and we will require the recipient to protect the information and use it only for the purpose it was provided.

CMS Required Disclaimer: We do not offer every plan available in your area. Currently we represent 7 organizations which offer 92 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Office use Only