Need to Schedule Medicare Plan Review Patient Information

We have partnered with Clarity Insurance Group again to help with our plan reviews this year!

Don't worry- some of the same faces you have seen in the past have joined the Clarity Insurance Group so you can expect the same personalized level of care you are used to. We are now able to provide help with not only Medicare Part D, but all aspects of Medicare!

Those who have used us in the past have loved their experience!

We look forward to serving you!

First Name*

Last Name*

Mobile Phone Number*

(Home number if no mobile number)

Email Address

Confirm Email Address

Date of Birth*

Are you a current patient of Bluegrass Pharmacy? (Current Patient = having your regular meds filled here in the past 6 months)*

YesNo

Zip code where you live:*

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

Advantage PlanTraditional and Part D (and possibly a Medigap/Medicare Supplement Plan)Not sure or new to Medicare

Today's Date*

Date

Will this be a meeting for one or two people?*

OneTwo

Do you give permission to Bluegrass Pharmacy to share your current medication list with Clarity Insurance Group?*

YesNot a patient of Bluegrass Pharmacy

Would you like to receive a flu shot and/or Covid shot when you come for your Medicare review? (Select all that apply)*

Flu shotCovid shotNo

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

YesNo

Will you bring a list of all of your current medications? (Sometimes we know that patients are forced by their insurance to get other medications elsewhere.)*

Yes

By submitting this form I am agreeing to receive texts and/or emails from Bluegrass Pharmacy and the Clarity Insurance Group.*

I agree

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:*