Medicare and Health Insurance Intake and Review Form

Medicare and Health Insurance

Intake and Review Form
Reminder

IFP AEP: November 1 - January 15

Medicare & Part D AEP: October 15 - December 7
Please complete the information below or print and return to:
Avanti Health First

1823 Ford Street Ste 104, Golden CO 80401

Phone: 303-278-2278

Email: hello@avantihealthfirst.com
Please provide the following information:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
County of Residence
Current Pharmacy
Primary Care Physician (PCP) Name

Specialist(s)

Dentist Name
Prescription Information

PLEASE: Do NOT include vitamins, supplements and other over-the-counter medications.

Example: Simvastatin | Tablet | 20 mg | 30

Medicare and Health Insurance