All information provided is Voluntary
Please return this form at least 48 hours prior to your appointment to avoid cancellation
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Please list all doctors, chiros, eye dr etc. that you see. Only complete the first 4 columns - the rest are office use.
Disclaimer: "We do not offer every plan available in your area. We are licensed in Oregon only and currently we represent seventeen Organizations which offer 101 products in your area. Please contact Medicare.gov or 1-800-MEDICARE, or your local State Health Insurance
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Prescription drug List (This is voluntary but allows us to properly research your coverage options)
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A. When Choosing a plan what are the most important features?
Rows
Not Important
Somewhat Improtant
Improtant
Very Important
Premium
Out of Pocket costs
Dental
Vision
Hearing
Chiro/Acup
Fitness
Over the Counter
RX/Pharm
PCP
Specialist
B. Other Products I have interest in
Rows
Not Interested
Interested
Life Insurance
Final Expense
Lont Term Care
Hospital Coverage
Other
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