Medicare Review & Plan Comparison Request

1

What’s your full name?

First Name

Last Name

2

What’s your date of birth?

Date

3

What is your state, county and zip code?

4

What’s the best phone number to reach you?

Area Code

Phone Number

5

Which email should Candace use to send your plan comparison?

example@example.com

6

Do you receive Extra Help (LIS) or Medicaid?

YESNO

7

What type of Medicare plan are you currently enrolled in?

Original Medicare (Part A & B)

Medicare Advantage (Part C)

Medicare Supplement (Medigap)

Medicare Part D (Prescription Drug Plan)

Employer based plan

Tricare, VA or Champ VA

Not currently enrolled

8

Current Plan Name/Carrier (if known)

9

Do you currently have a Part D prescription plan?

10

What pharmacy do you prefer to use?

11

You can list your current prescriptions here if you’d like Candace to check coverage and savings.

12

Would you like Candace to check if your doctor(s) are in-network? If so, please list them below.

13

Which of the following aspects are most important to you in a Medicare plan? (Select all that apply)

Low monthly premiums

Low deductibles and co-pays

Comprehensive prescription drug coverage

Dental, vision, and hearing benefits

Access to a wide network of doctors and hospitals

Travel coverage

Fitness programs (e.g., gym memberships)

Telehealth services

14

Do you currently or have you been previously treated for any of the following:

Diabetes

Chronic lung disease

Cardiovascular disorder

Stroke

End-stage renal disease

15

Do you have any specific questions or concerns about your Medicare coverage that you would like us to address?

16

When’s the best time for Candace to reach out?

Morning (9–12)

Afternoon (12–4)

Evening (4–7)

Anytime works 🌿

17

By submitting, you agree to be contacted by a licensed agent (Candace Larry) regarding Medicare options. This is a free, no-obligation consultation. Covered by Candace is an independent agency, not affiliated with Medicare or CMS.

I agree and I understand