Medicare Annual Enrollment Phone Appointment

Medicare Annual Enrollment

Please complete the following information. We will review the information and follow up via phone at the scheduled time with a personalized recommendation for your Medicare drug plan.
Full Name*

First NameLast Name
Date of birth*

MonthDayYear
Date
Physical Address (no PO box) *

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address (if different than physical address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number*
Please enter the best contact number for the pharmacy staff to call you at your scheduled appointment.
Medicare Beneficiary Identifier
Alphanumeric number on your Medicare Red White and Blue card
Do you get help with your costs from one of these programs?

MedicaidSupplemental Security IncomeMedicare Savings ProgramExtra HelpI'm not sureI don't get help from any of these programs
To provide the best recommendations, we need an accurate and comprehensive list of your medications. If you do not already fill all of your medications at HealthRidge, please provide any other medications that you take.
Any other general questions, comments, or concerns regarding Medicare?
If you want Taylor to sign you up for your plan, please indicate if you prefer to have your monthly premium taken out of your Medicare check or billed to you in the mail.
Appointment*
Please note, this is a phone appointment. Taylor will call you at the listed phone number at the selected date and time.
Should be Empty: