1529 Washington Street
Vicksburg, Mississippi 39180
Medicare Advantage Evaluation
Oklahoma, Texas, Louisiana, and Mississippi
Are you currently on MAPD? Please check your current plan or write it below.
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Wellcare
Humana
United Health Care
Other
Who is your primary Physician?
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Do you see any other Physicians?
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Have you been diagnosed with Diabetes, Cardiovascular, or Respiratory Conditions?
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Yes
No
If yes, what medications are you taking for that condition only?
Personal Information
Name
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
SSN (only if you do not have a Medicare card)
Date of Birth
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Month
-
Day
Year
Date
Medicaid Number
Medicare Number
Medicare Part A Date
Date
Medicare Part B Date
Date
Signature
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Date
*
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Month
-
Day
Year
Date
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Scope of Sales Appointment Confirmation
The Centers for Medicare & Medicaid Services requires agents to document the scope of a marketing appointment prior to any individual sates meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized presentative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.
By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above.
Please note, the person who wit[ discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrolment in a p[an. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.
Beneficiary or Authorized Representative Signature and Signature Date
Signature
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Date
*
-
Month
-
Day
Year
Date
If you are a representative, please sign above and print below
Name
First Name
Last Name
Your relationship to the Beneficiary
Please verify that you are human
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: