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26
Questions
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HIPAA
Compliance
1
Name
*
This field is required.
First Name
Last Name
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2
Date of Birth
*
This field is required.
-
Date
Month
Day
Year
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3
Home Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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4
*
This field is required.
County
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5
Personal Email
*
This field is required.
example@example.com
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6
Preferred Contact Phone Number
*
This field is required.
Please enter a valid phone number.
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7
Are You Enrolled in Medicare?
*
This field is required.
No
Yes
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8
Do you have both Medicare Parts A and B
*
This field is required.
No
Yes
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9
Which Part
Part A
Part B
Neither
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10
Do you have Medicaid?
*
This field is required.
No
Yes
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11
Do you give me permission to verify your Medicaid and Medicare status to find the best plan for you?
No
Yes
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12
What is your Medicaid Number?
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13
What is your Medicare Number?
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14
Do You receive Extra Help?
*
This field is required.
No
Yes
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15
Do You Currently Have Health Insurance?
*
This field is required.
No
Yes
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16
Current Health Insurance Type
*
This field is required.
Job-based health insurance
Private pay health insurance
Medicare
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17
Name of Current Insurance Company
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18
Date New Coverage is Needed
*
This field is required.
-
Date
Month
Day
Year
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19
What would you like to improve on your current plan?
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20
For your new plan are their certain services you want to make sure are covered?
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21
Please Indicate Your Basic Understanding of Medicare
*
This field is required.
I could use a quick refresher on Medicare basics
I have a solid understanding of how Medicare works
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22
Do You Take Prescription Medications Currently?
*
This field is required.
No
Yes
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23
How many medications do you currently take?
*
This field is required.
1 - 10
10 or more
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24
Tell Us About Your Current Prescriptions
Prescription Name (brand required?)
Dosage(cap/tab)
Monthly Quantity
Refill Frequency
Rx 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Rx 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Rx 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Rx 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Rx 5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Rx 6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Rx 7
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Rx 8
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Rx 9
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Rx 10
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Rx 1
Rx 2
Rx 3
Rx 4
Rx 5
Rx 6
Rx 7
Rx 8
Rx 9
Rx 10
Prescription Name (brand required?)
Row 0, Column 0
Dosage(cap/tab)
Row 0, Column 1
Monthly Quantity
Row 0, Column 2
Refill Frequency
Row 0, Column 3
Prescription Name (brand required?)
Row 1, Column 0
Dosage(cap/tab)
Row 1, Column 1
Monthly Quantity
Row 1, Column 2
Refill Frequency
Row 1, Column 3
Prescription Name (brand required?)
Row 2, Column 0
Dosage(cap/tab)
Row 2, Column 1
Monthly Quantity
Row 2, Column 2
Refill Frequency
Row 2, Column 3
Prescription Name (brand required?)
Row 3, Column 0
Dosage(cap/tab)
Row 3, Column 1
Monthly Quantity
Row 3, Column 2
Refill Frequency
Row 3, Column 3
Prescription Name (brand required?)
Row 4, Column 0
Dosage(cap/tab)
Row 4, Column 1
Monthly Quantity
Row 4, Column 2
Refill Frequency
Row 4, Column 3
Prescription Name (brand required?)
Row 5, Column 0
Dosage(cap/tab)
Row 5, Column 1
Monthly Quantity
Row 5, Column 2
Refill Frequency
Row 5, Column 3
Prescription Name (brand required?)
Row 6, Column 0
Dosage(cap/tab)
Row 6, Column 1
Monthly Quantity
Row 6, Column 2
Refill Frequency
Row 6, Column 3
Prescription Name (brand required?)
Row 7, Column 0
Dosage(cap/tab)
Row 7, Column 1
Monthly Quantity
Row 7, Column 2
Refill Frequency
Row 7, Column 3
Prescription Name (brand required?)
Row 8, Column 0
Dosage(cap/tab)
Row 8, Column 1
Monthly Quantity
Row 8, Column 2
Refill Frequency
Row 8, Column 3
Prescription Name (brand required?)
Row 9, Column 0
Dosage(cap/tab)
Row 9, Column 1
Monthly Quantity
Row 9, Column 2
Refill Frequency
Row 9, Column 3
1
of 10
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25
Tell Us About Your Current Prescriptions
Prescription Name (brand required?)
Dosage(cap/tab)
Monthly Quantity
Refill Frequency
Rx 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Rx 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Rx 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Rx 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Rx 5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Rx 6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Rx 7
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Rx 8
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Rx 9
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Rx 10
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Rx 11
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Rx 12
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Rx 13
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Rx 14
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Rx 15
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Row 14, Column 3
Rx 16
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Row 15, Column 3
Rx 17
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Rx 18
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Rx 19
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Rx 20
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Rx 1
Rx 2
Rx 3
Rx 4
Rx 5
Rx 6
Rx 7
Rx 8
Rx 9
Rx 10
Rx 11
Rx 12
Rx 13
Rx 14
Rx 15
Rx 16
Rx 17
Rx 18
Rx 19
Rx 20
Prescription Name (brand required?)
Row 0, Column 0
Dosage(cap/tab)
Row 0, Column 1
Monthly Quantity
Row 0, Column 2
Refill Frequency
Row 0, Column 3
Prescription Name (brand required?)
Row 1, Column 0
Dosage(cap/tab)
Row 1, Column 1
Monthly Quantity
Row 1, Column 2
Refill Frequency
Row 1, Column 3
Prescription Name (brand required?)
Row 2, Column 0
Dosage(cap/tab)
Row 2, Column 1
Monthly Quantity
Row 2, Column 2
Refill Frequency
Row 2, Column 3
Prescription Name (brand required?)
Row 3, Column 0
Dosage(cap/tab)
Row 3, Column 1
Monthly Quantity
Row 3, Column 2
Refill Frequency
Row 3, Column 3
Prescription Name (brand required?)
Row 4, Column 0
Dosage(cap/tab)
Row 4, Column 1
Monthly Quantity
Row 4, Column 2
Refill Frequency
Row 4, Column 3
Prescription Name (brand required?)
Row 5, Column 0
Dosage(cap/tab)
Row 5, Column 1
Monthly Quantity
Row 5, Column 2
Refill Frequency
Row 5, Column 3
Prescription Name (brand required?)
Row 6, Column 0
Dosage(cap/tab)
Row 6, Column 1
Monthly Quantity
Row 6, Column 2
Refill Frequency
Row 6, Column 3
Prescription Name (brand required?)
Row 7, Column 0
Dosage(cap/tab)
Row 7, Column 1
Monthly Quantity
Row 7, Column 2
Refill Frequency
Row 7, Column 3
Prescription Name (brand required?)
Row 8, Column 0
Dosage(cap/tab)
Row 8, Column 1
Monthly Quantity
Row 8, Column 2
Refill Frequency
Row 8, Column 3
Prescription Name (brand required?)
Row 9, Column 0
Dosage(cap/tab)
Row 9, Column 1
Monthly Quantity
Row 9, Column 2
Refill Frequency
Row 9, Column 3
Prescription Name (brand required?)
Row 10, Column 0
Dosage(cap/tab)
Row 10, Column 1
Monthly Quantity
Row 10, Column 2
Refill Frequency
Row 10, Column 3
Prescription Name (brand required?)
Row 11, Column 0
Dosage(cap/tab)
Row 11, Column 1
Monthly Quantity
Row 11, Column 2
Refill Frequency
Row 11, Column 3
Prescription Name (brand required?)
Row 12, Column 0
Dosage(cap/tab)
Row 12, Column 1
Monthly Quantity
Row 12, Column 2
Refill Frequency
Row 12, Column 3
Prescription Name (brand required?)
Row 13, Column 0
Dosage(cap/tab)
Row 13, Column 1
Monthly Quantity
Row 13, Column 2
Refill Frequency
Row 13, Column 3
Prescription Name (brand required?)
Row 14, Column 0
Dosage(cap/tab)
Row 14, Column 1
Monthly Quantity
Row 14, Column 2
Refill Frequency
Row 14, Column 3
Prescription Name (brand required?)
Row 15, Column 0
Dosage(cap/tab)
Row 15, Column 1
Monthly Quantity
Row 15, Column 2
Refill Frequency
Row 15, Column 3
Prescription Name (brand required?)
Row 16, Column 0
Dosage(cap/tab)
Row 16, Column 1
Monthly Quantity
Row 16, Column 2
Refill Frequency
Row 16, Column 3
Prescription Name (brand required?)
Row 17, Column 0
Dosage(cap/tab)
Row 17, Column 1
Monthly Quantity
Row 17, Column 2
Refill Frequency
Row 17, Column 3
Prescription Name (brand required?)
Row 18, Column 0
Dosage(cap/tab)
Row 18, Column 1
Monthly Quantity
Row 18, Column 2
Refill Frequency
Row 18, Column 3
Prescription Name (brand required?)
Row 19, Column 0
Dosage(cap/tab)
Row 19, Column 1
Monthly Quantity
Row 19, Column 2
Refill Frequency
Row 19, Column 3
1
of 20
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26
Do You Have a Preferred Pharmacy?
*
This field is required.
Yes
No
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27
Preferred Retail Pharmacy Name
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28
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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29
Do You Have a Primary Care Doctor?
*
This field is required.
No
Yes
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Name of Primary Care Doctor
First Name
Last Name
City/Town
PCP
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
PCP
First Name
Row 0, Column 0
Last Name
Row 0, Column 1
City/Town
Row 0, Column 2
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31
Do You See Other Specialist Doctors on a Regular Basis?
*
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No
Yes
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32
Names of Current Specialist Doctors
First Name
Last Name
Specialty
City/Town
Specialist 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Specialist 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Specialist 3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Specialist 4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Specialist 5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Specialist 6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Specialist 7
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Specialist 8
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Specialist 9
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Specialist 10
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Specialist 1
Specialist 2
Specialist 3
Specialist 4
Specialist 5
Specialist 6
Specialist 7
Specialist 8
Specialist 9
Specialist 10
First Name
Row 0, Column 0
Last Name
Row 0, Column 1
Specialty
Row 0, Column 2
City/Town
Row 0, Column 3
First Name
Row 1, Column 0
Last Name
Row 1, Column 1
Specialty
Row 1, Column 2
City/Town
Row 1, Column 3
First Name
Row 2, Column 0
Last Name
Row 2, Column 1
Specialty
Row 2, Column 2
City/Town
Row 2, Column 3
First Name
Row 3, Column 0
Last Name
Row 3, Column 1
Specialty
Row 3, Column 2
City/Town
Row 3, Column 3
First Name
Row 4, Column 0
Last Name
Row 4, Column 1
Specialty
Row 4, Column 2
City/Town
Row 4, Column 3
First Name
Row 5, Column 0
Last Name
Row 5, Column 1
Specialty
Row 5, Column 2
City/Town
Row 5, Column 3
First Name
Row 6, Column 0
Last Name
Row 6, Column 1
Specialty
Row 6, Column 2
City/Town
Row 6, Column 3
First Name
Row 7, Column 0
Last Name
Row 7, Column 1
Specialty
Row 7, Column 2
City/Town
Row 7, Column 3
First Name
Row 8, Column 0
Last Name
Row 8, Column 1
Specialty
Row 8, Column 2
City/Town
Row 8, Column 3
First Name
Row 9, Column 0
Last Name
Row 9, Column 1
Specialty
Row 9, Column 2
City/Town
Row 9, Column 3
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33
Do You Have a Dentist?
*
This field is required.
No
Yes
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34
Dental Providers
First Name
Last Name
Type
City/Town
Dental 1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Dental 2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Dental 1
Dental 2
First Name
Row 0, Column 0
Last Name
Row 0, Column 1
Type
Row 0, Column 2
City/Town
Row 0, Column 3
First Name
Row 1, Column 0
Last Name
Row 1, Column 1
Type
Row 1, Column 2
City/Town
Row 1, Column 3
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35
Notes or Important Additional Providers (hospitals, rehab facilities, etc.)
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36
What's most important to you?
A plan with low or no medical co-pays
A plan with low monthly premiums
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37
What's most important to you?
A plan with nationwide in-network coverage
A plan with low monthly premiums
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38
*NOTE: Emergency room coverage is available worldwide on all plans.
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39
What's most important to you?
A plan that includes dental, vision and health club benefits
A plan with low or no medical co-pays
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40
Do you know what type of Medicare plan you are interested in?
Medicare Advantage (Part C) that includes Part D
Medicare Supplement ("MediGap") + Part D
I do not know yet
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