All information provided is Voluntary
Please return this form at least 48 hours prior to your appointment to avoid cancellation
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
Prescription drug List (This is voluntary but allows us to properly research your coverage options)
A. When Choosing a plan what are the most important features?
Out of Pocket costs
Over the Counter
B. Other Products I have interest in
Lont Term Care
Should be Empty: