What you will need to complete your form.
- Medicare Insurance Card (Original Medicare Card)
- Names of your doctor, specialist, etc..
- List of medications and preferred pharmacies
- Names of current insurance companies and rates of the premium.
- Please list any future testing, procedures, therapies, or new health concerns.
This form should take 10 to 15 minutes to complete. Please answer the questions with as much detail and accuracy as possible.
***(Optional) We have provided short explainer videos along the way in case you do not understand what we are asking for or why we are asking for it.