NOTE: Please prepare all items before filling out as the form may time out if you walk away and will have to start over again.

For Primary Care Physician and Doctor Specialist

First and Last Name (Please make sure the spelling is accurate.)
Phone Number
Field of Medicine (eg. Dentist/ Eye Doctor)
Medical Group (eg. Baptist)

For Medication information

Name
Strength/Dosage
How often do you take them
Dosage Form

Doctor's Information

Please make sure the spelling is accurate.

Primary Care Physician's Last Name *

Primary Care Physician's First Name *

Primary Care Physician's Name Facility *

Primary Care Physician's Phone Number *

Please rank your providers based on importance when reviewing 2026 plan options. Use the scale below for each provider you list: *

1 - Must keep this provider (dealbreaker if not in-network)

2 - Prefer to keep this provider, but willing to change if benefits are better

3 - Open to finding a new provider (need help with options)

Doctor Specialists Information

Please make sure the spelling is accurate.

eg. Smith - John Do - (904) 123-4567 - Dentist - Smile Dental

Please rank your providers based on importance when reviewing 2026 plan options. Use the scale below for each provider you list:

1 - Must keep this provider (dealbreaker if not in-network)

2 - Prefer to keep this provider, but willing to change if benefits are better

3 - Open to finding a new provider (need help with options)

Please rank your providers based on importance when reviewing 2026 plan options. Use the scale below for each provider you list:

1 - Must keep this provider (dealbreaker if not in-network)

2 - Prefer to keep this provider, but willing to change if benefits are better

3 - Open to finding a new provider (need help with options)

Please rank your providers based on importance when reviewing 2026 plan options. Use the scale below for each provider you list:

1 - Must keep this provider (dealbreaker if not in-network)

2 - Prefer to keep this provider, but willing to change if benefits are better

3 - Open to finding a new provider (need help with options)

Please rank your providers based on importance when reviewing 2026 plan options. Use the scale below for each provider you list:

1 - Must keep this provider (dealbreaker if not in-network)

2 - Prefer to keep this provider, but willing to change if benefits are better

3 - Open to finding a new provider (need help with options)

Please rank your providers based on importance when reviewing 2026 plan options. Use the scale below for each provider you list:

1 - Must keep this provider (dealbreaker if not in-network)

2 - Prefer to keep this provider, but willing to change if benefits are better

3 - Open to finding a new provider (need help with options)

eg. Atorvastatin - 20mg - 1/day - tablet

Important Note:
Please list only the medications you anticipate taking in 2026.

If you take a brand-name medication, write the brand name.
If you take a generic, write the generic name (not the brand).

We often see people list the brand when they’re actually taking the generic, and this can really mess up your quotes!

To make sure your plan is accurate, we need all information—including correct spelling—received in

advance.

Unfortunately, due to time constraints, we won’t be able to make adjustments later.

Thank you for helping us get it right the first time!

How Often #1

Dosage Form #1

How Often #2

Dosage Form #2

How Often #3

Dosage Form #3

How Often #4

Dosage Form #4

How Often #5

Dosage Form #5

How Often #6

Dosage Form #6

How Often #7

Dosage Form #7

How Often #8

Dosage Form #8

How Often #9

Dosage Form #9

How Oftem #10

Dosage Form #10

How Often #11

Dosage Form #11

How Often #12

Dosage Form #12

How Often #13

Dosage Form #13

How Often #14

Dosage Form #14

How Often #15

Dosage Form #15

Special Medicare Advantage plans and/or extra benefits may be available for individuals with certain chronic conditions. To determine if you may qualify, please review the list below and check any conditions you have been diagnosed with.

Please note: There is specific criteria that must be met to qualify as “chronically ill,” but in general, you need to have at least one of the following conditions.

Chronic Diseases And Conditions. To see if you qualify for special benefits, do you have or have you been told you have any of the following *

If you selected "Other chronic condition(s)," please write them in the space provided:

Agent's Name

List any specific things the Mere Benefits agent should be aware of when looking at options for 2026, including any must-haves, things you don’t use, or anything you want to avoid.

We will do our best to find a plan that accommodates your wishes, but please understand there are no perfect options.

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