Doctor List - Info 2026 for web

Doctor List for Medicare Advantage Plans

I am voluntarily sharing this information with Imagine Insurance Advisors (IIA) so they can make a recommendation. I understand IIA will only recommend plans that they can support and receive compensation for. For info on all plans available, I can visit Medicare at www.Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).

ONLY FILL THIS OUT IF YOU WANT TO LOOK AT A MEDICARE ADVANTAGE PLAN. It is not needed if you have a supplement and drug plan.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Today's Date*

MonthDayYear
Date
Instructions: Please complete this form in its entirety. Include all doctors who provide your care or that you would see. Use one copy per household member.
Primary Care Doctor First and Last Name*
Street office is on
Enter street Primary Care Doc is on
City and State*
City and State PCP is in
Are you willing to change this doc?
Preferred Hospital
Primary Hospital you go to
Other Hospitals you want in network
Enter the name of the other hospitals you want to go to.
Specialist 1 - First and Last Name
Spec 1 - Street office is on
Spec 1 - City and State located in
Spec 1 - Specialty
Specialty - ie. cardiologist, nephrologist
Spec 1 - Are you willing to change this doc?
Specialist 2 - First and Last Name
Spec 2 - Street office is on
Spec 2 - City and State located in
Spec 2 - Specialty
Specialty - ie. cardiologist, nephrologist
Spec 2 - Are you willing to change this doc?
Specialist 3 First and Last Name
Spec 3 - Street office is on
Spec 3 - City and State located in
Spec 3 - Specialty
Specialty - ie. cardiologist, nephrologist
Spec 3 - Are you willing to change this doc?
Specialist 4 - First and Last Name
Spec 4 - Street office is on
Spec 4 - City and State located in
Spec 4 - Specialty
Specialty - ie. cardiologist, nephrologist
Spec 4 - Are you willing to change this doc?
Your Dentist - First and Last Name
Enter your Dentist's name
Dentist - Street office is on
Dentist - City and State located in
Dentist - Are you willing to change this dentist?
Do you have more doctors to add?
If you have more doctors, please fill out an additional form for those doctors.
If you have more doctors to list, please start another doctor form and put CONTINUED after your last name. Check the box above.
Should be Empty: