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)

Note: If you are seeing a PA (Physician Assistant) or APRN (Advanced Practice Registered Nurse), please add that designation to their name. If so, please also include the name of their office or clinic.

For Medication information

  • Name

  • Strength/Dosage

  • How often do you take them

  • Dosage Form

Doctor's Information

Please make sure the spelling is accurate.

Doctor Specialists Information

Please make sure the spelling is accurate.

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

Drug Information

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!


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.

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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