Medicare Plan Review Patient Information

We have teamed with the Mathis Insurance Group to help with our plan reviews this year!

The people who have cared for you for years are the same people who are now agents! We now can offer more detailed information and can help with ALL aspects of Medicare instead of just Part D!

After you complete your patient information you will be taken to the scheduling page.

Thanks!

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Confirm Email

example@example.com

Birth Date

MonthDayYear

Are you a current patient of Lascassas Drugs? (Have had your regular medications filled here for at least 6 months)

What is the zip code where you live?

Please list your current medications

What is your current plan?

Is your plan an "Advantage" plan or traditional Medicare with Part D coverage?

Do you have a Medicare supplement plan?

How much is your Medicare Supplement (or MediGap) Plan?

Who is your current Medicare Supplement company? (Type "Not Sure" if you don't know)

Do you give permission for Lascassas Drugs or Watertown Drugs to share your current medication list with the Mathis Insurance Group?

Have you received any paperwork regarding your CURRENT plan regarding 2025?

Will you bring that paperwork with you to your appointment?

Will you bring a list of all your current medications with you to your appointment? (We understand that patients are sometimes forced by their insurance to get medications elsewhere)

Will this meeting be for one or two people?

If at all possible both people should attend the meeting.

Name (Second Person)

First NameLast Name

Birth Date (Second Person)

MonthDayYear

What is your current plan? (Second Person)

Do both parties give permission for Lascassas Drugs or Watertown Drugs to share your current medication list with the Mathis Insurance Group?

Do you or your spouse qualify for any additional governmental help?

Do you or your spouse have Tricare or VA benefits?

Is there anything else we need to know about your medications or current plan?

Would you like to receive any vaccines when you come in for your Medicare plan review?

By submitting this form I am agreeing to receive texts and/or emails from Lascassas Drugs and the Mathis Insurance Group

Today's Date

Date

By signing this form, you agree to allowing a sales agent to contact you to discuss your Medicare plans. Please note, the person who will 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 enrollment in a plan. 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.

Please use your mouse or finger (if you have a touchscreen) to sign below:

Please use your mouse or finger (if you have a touchscreen) to sign below (spouse or second person):

Appointment

Medicare Plan Review Patient Information

Information for Second Person