Medicare and Health Insurance Enrollment:

Medicare and Health Insurance Enrollment:

Schedule a 30-minute consultation with one of our partner agents and you could save thousands in health care costs! With Medicare season upon us, put your loved ones first and let our team of trained licensed agents optimize your health plan.

How it works: Schedule a time to speak with a licensed agent and complete the form to allow for a efficent meeting. Answer to the best of your ability. The required field are marked.

What do I bring with me to the appointment? Bring all the information you have, including all insurance cards and any insurance statements along with questions.

Note: Annual Enrollment Period - Oct 15 to Dec 7 every year - Opportunity for Change in Medicare Plan. For Yearly renewal please make sure to schedule the appointment in that time frame
Please pick a day and time below (to see next month's appointments, click on the down arrow next to the current month) *If you are coming in with spouse select the closest appointment together & we will take you in together***
Name*

First NameMiddle NameLast Name
DOB*
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCounty
E-Mail*
example@example.com
Referred By
Cell Phone*
Format: (000) 000-0000.
Home Phone
Format: (000) 000-0000.
Medicare ID (Red/White/Blue card)
Part A Effective Date

MonthDayYear
Date
Part B Effective Date

MonthDayYear
Date
Medicaid
Are you currently employed?

NoYes
If employed - Will/does your employer offer a Medicare plan?

YesNo
Is your spouse still employed?

YesNo
If employed - Will/does your spouse's employer offer a Medicare plan?

YesNo
For EXTRA HELP: Is your monthly income below $1,903 in 2024 ($2,575 for couples)?

YesNo
For Extra HELP: Are you a Veteran?

YesNo:
MEDICARE NEEDS ANALYSIS
To evaluate your Current Medical/Dental/Vision Plans
Medicare Advantage Prescription Drug (MAPD)
Type "N/A" if not applicable
MAPD Monthly Premium $$
Type "N/A" if not applicable
If you have Medicare Supplemental Coverage who is it through?
Type "N/A" if not applicable
Monthly premium of Supplemental $$
Type "N/A" if not applicable
If you have Medicare Part D Coverage who is it through?
Type "N/A" if not applicable
Monthly premium of Part D plan $$
Type "N/A" if not applicable
Medical coverage: from Employer
Monthly Premium $$
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
If COBRA
COBRA Premium $$
Cobra Start Date

MonthDayYear
Date
Cobra End Date

MonthDayYear
Date
If End-Stage Renal Disease (ESRD) indicate Yes and list
Are you a Smoker:

Non- SmokerSmoker
Who is your insurance provider for Dental?
Type "N/A" if not applicable
Monthly premium for Dental $$
Type "N/A" if not applicable
Who is your insurance provider for Vision?
Type "N/A" if not applicable
Monthly premium for Vision $$
Type "N/A" if not applicable
Who is your insurance provider for Hearing?
Monthly premium for Hearing $$
Prescriptions (Optional)

Lititz Apothecary customers can skip this question
Please write what prescription medications you are on; include Name/Dosage and monthly cost.
MEDICARE NEEDS ANALYSIS
Did a Beneficiary Volunteer Prescription Information?

YesNo
Do you have a Pharmacy Preference?
Do you have a Hospital Preference?
Doctors
List your Primary Care Doctor (PCP)
List any specialist you see?
Type "N/A" if not applicable
List your preferred or current Dentist
List your preferred or current Eye Doctor
List any Additional Healthcare provider (i.e. Chiropractor, Physical Therapist, Audiologist, etc)
List any additional helpful benefits (i.e. Transportation, gym membership, Over-the-Counter cards, etc.):
By completing this form you are providing authorization for a licensed agent from PA Health Consulting LLC to contact you via the phone and/or email provided. *
Should be Empty:

MEDICARE NEEDS ANALYSIS

To evaluate your Current Medical/Dental/Vision Plans

Prescriptions (Optional)

MEDICARE NEEDS ANALYSIS

Doctors