Annual Coverage Review Form
Share your updated contact, coverage, and provider details so we can review your fit ahead of Medicare Annual Enrollment Period and Marketplace Open Enrollment Period. Please fill out where applicable.
Contact Information
First Name
*
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Street Address
*
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
ZIP Code
*
What type of coverage would you like reviewed?
*
Medicare
Individual/Family Marketplace
Not Sure
Coverage Changes
Are you currently satisfied with your coverage?
*
Yes
No
Not Sure
Please tell us what concerns you have with your current coverage.
Healthcare Providers
Would you like to provide your doctors?
*
Yes
No
Doctor Entries
Prescription Medications
Would you like to provide your medications?
*
Yes
No
Medication entries
If you selected Yes, please add one row per medication.
You may list as many medications as needed.
Pharmacy Information
Preferred Pharmacy Name
Pharmacy ZIP Code
Do you use mail-order prescriptions?
Yes
No
Medicare-Specific Questions
Do you currently receive Extra Help/LIS?
Yes
No
Not Sure
Do you currently receive Medicaid?
Yes
No
Do you travel frequently or live in multiple states during the year?
Yes
No
Are there any upcoming surgeries or treatments planned for next year?
*
Yes
No
Please provide details.
Marketplace-Specific Questions
Estimated household income for next year
Number of people in household
Household members
Household Members (other than you, that should be included on coverage)
Has anyone gained access to employer-sponsored coverage?
Yes
No
Consent
I certify that the information provided is accurate to the best of my knowledge and I authorize Surefire Medical Protection to contact me regarding my coverage review.
*
I certify that the information provided is accurate to the best of my knowledge and I authorize Surefire Medical Protection to contact me regarding my coverage review.
Electronic Signature
*
Submit My Review Request
Submit My Review Request
Should be Empty: