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  • Medicare Plan Comparison Worksheet

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Please complete the section below using the information from your Medicare Card.

    An example has been provided if you are unsure of what your Medicare card looks like.
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  • Part A Coverage Start Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Part B Coverage Start Date:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Income/Subsidy Information

  • Are you receiving assistance through a Medicare Savings Program (MSP)?

  • Monthly Gross Income

  • What Insurance coverage do you currently have? Please check all that apply
  • I am interested in reviewing:
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  • Part C Medicare Advantage Only:To help us make sure your doctors and other providers are in the plan's network and service area we need the following: Include Dentist/Optometrist if applicable

  • To help us make sure your doctors and other providers are in the plan's network and service area we need the following: Include Dentist/Optometrist if applicable
    Rows
  • My doctors are associated with the following hospital systems:
  • SHIP Communication Preferences:
  • Other Services
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  • For SHIP Use Only

  • Follow-up Date:
     - -
    2 digit month, 2 digit day, 4 digit year
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  • DOB:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Please list each of your prescriptions in the columns below. Include any form of medication prescribed by a medical doctor including injections, breathing treatments, ointments, creams, etc..
    DO NOT INCLUDE OVER THE COUNTER (OTC), MEDICINES, VITAMINS ETC

  • DO NOT INCLUDE OVER THE COUNT ER (OTC), MEDICINES, VITAMINS ETC
    Rows
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  • Should be Empty: