Current Medicare Client - please update your Information

Tonya LeGrande & Associates, LLC

1120 A St. PO Box 429 Schuyler, NE 68661 402-352-6610
MEDICARE ANNUAL REVIEW
Our Agency Provides Service & Savings!

Thank you for taking time to complete this information. As part of our service, we want to make sure we find cost-effective coverage that is tailored to your needs. This information is beneficial in helping us do that. If you have any questions or concerns completing this, please call us directly at: 402-352-6610 or e-mail us at: insurance@tonyalegrande.com.
Name*
Date of Birth*

MonthDayYear
Date
Phone*
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Address*

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ST*
Zip*
E Mail*
example@example.com
YN
Single (please mark this if widowed or divorced as well)Married
YOUR MEDICATIONS:
YN
If "YES" please complete your pharmacy of choice and Medication List.
Pharmacy Name
Pharmacy Phone Number
Format: (000) 000-0000.
Medication #1
Medication #1 dosage
Medication #1 - Condition it is treating
Medication #2
Medication #2 Dosage
Medication #2 - Condition it is treating
Medication # 3
Medication #3 Dosage
Medication #3 - Condition it is treating
Medication # 4
Medication #4 Dosage
Medication #4 - Condition it is treating
Medication # 5
Medication #5 Dosage
Medication #5 - Condition it is treating
Medication # 6
Medication #6 Dosage
Medication #6 - Condition it is treating
Medication # 7
Medication #7 Dosage
Medication #7 - Condition it is treating
Medication # 8
Medication #8 Dosage
Medication #8 - Condition it is treating
If you have more medications, please e-mail us a list of all your medications at insurance@tonyalegrande.com. Be sure to list Medication Name, Dosage, and Condition it is treating.

DO YOU HAVE INTEREST IN MEDICARE ADVANTAGE / COST PLANS?

If you have interest in Medicare Advantage or Cost Plans, we will need to know the following information: These plans have Networks and we want to moke sure your providers are IN-NETWORK
Primary Care Provider
Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Specialist Name:
Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Specialist Name:
Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Other Medical Providers Not Listed:
HOW DO YOU PREFER WE CONTACT YOU REGARDING YOUR REVIEW?
PHONEE-MAIL
Do you have a family member/friend you would like us to communicate with?
WE WANT TO KNOW YOUR CONCERNS/NEEDS:

Many of our clients have found these low-cost policies bring them peace of mind. We want to make sure we do a thorough review to take care of your concerns and needs. Please let us know how we can better serve you.
YESNO
YESNO
YESNO
Dentist Name
Dentist Phone
Format: (000) 000-0000.
City
State
Zip
Please complete your spouse's information below:
YOUR SPOUSE'S INFORMATION:
Name
Date of Birth

MonthDayYear
Date
Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
E-Mail
example@example.com
YN
YOUR SPOUSE'S MEDICATIONS & PHARMACY:
YESNO
Pharmacy Name
Pharmacy Phone Number
Format: (000) 000-0000.
Medication #1
Medication #1 Dosage
Medication #1 - Condition it is treating
Medication #2
Medication #2 Dosage
Medication #2 - Condition it is treating
Medication #3
Medication #3 Dosage
Medication #3 - Condition it is treating
Medication #4
Medication #4 Dosage
Medication #4 - Condition it is treating
Medication #5
Medication #5 Dosage
Medication #5 - Condition it is treating
Medication #6
Medication #6 Dosage
Medication #6 - Condition it is treating
Medication #7
Medication #7 Dosage
Medication #7 - Condition it is treating
Medication #8
Medication #8 Dosage
Medication #8 - Condition it is treating
If your spouse has more medications, please e-mail us a list of all their medications at insurance@tonyalegrande.com. Be sure to list Medication Name, Dosage, and Condition it is treating.
DOES YOUR SPOUSE HAVE INTERST IN MEDICARE ADVANTAGE OR COST PLANS?
If your spouse has interest in Medicare Advantage or Cost Plans, we need to have their health provider's information.
Spouse's Primary Care Provider
Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Spouse's Specialist
Phone
Format: (000) 000-0000.
Address
City
State
Zip
Specialist
Phone
Format: (000) 000-0000.
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State
Zip
Other
I am on MedicaidI have Low Income Subsidy (EXTRA HELP)
By signing below, / will not hold Tonya LeGrande & Associates, LLC liable for incorrect information / may have provided in this review.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Tonya LeGrande & Associates, LLC

MEDICARE ANNUAL REVIEW

Our Agency Provides Service & Savings!

YOUR MEDICATIONS:

DO YOU HAVE INTEREST IN MEDICARE ADVANTAGE / COST PLANS?

HOW DO YOU PREFER WE CONTACT YOU REGARDING YOUR REVIEW?

WE WANT TO KNOW YOUR CONCERNS/NEEDS:

Please complete your spouse's information below:

YOUR SPOUSE'S INFORMATION:

YOUR SPOUSE'S MEDICATIONS & PHARMACY:

DOES YOUR SPOUSE HAVE INTERST IN MEDICARE ADVANTAGE OR COST PLANS?