Medicare Plan Review Patient Information

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.
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)*

YesNo
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?*

Advantage planTraditional and Part D (with or without a MediGap/Medicare supplement plan)Not sure
Do you have a Medicare supplement plan?*

Plan GPlan FUnsureNoOther
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?*

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

YesNo
Will you bring that paperwork with you to your appointment?

YesNo
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)*

Yes
Will this meeting be for one or two people?

OneTwo
If at all possible both people should attend the meeting.

I understand
Information for Second Person
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?

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

YesYes - I/We also have TenncareI think we should but we don't know how to applyI think soNot sureNo
Do you or your spouse have Tricare or VA benefits?

YesNo
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?

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

I agree
Today's Date*

MonthDayYear
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:*

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

Clear
Appointment*
Should be Empty:

Medicare Plan Review Patient Information

Information for Second Person