Contact Info

First Name *

Last Name

Date of Birth:

Gender

Phone

Email

Address

ZIP Code:

County

State

Medicare ID

Example Medicare ID above

Medicare ID Number: *

* PLEASE USE CAPITAL LETTERS LIKE THIS *

Part A:

Part B:

Receiving Extra Help/L.I.S.?

Preferred Providers:

👩‍⚕️ PCP:

🦷 Preferred Dentist

🏥 Preferred Hospital:

💊 Preferred Pharmacy:

How many doctors do you currently see?

Current Plan Info:

Current Monthly Plan Cost:

$

Current Monthly Average Drug Cost:

$

Please input the AVERAGE amount YOU spend monthly on medicine.

👎 What do you NOT like about your current plan?

👍 What do you like about your current plan?

Additional Info

Upload Screenshots/Images:

Current Insurance ID Card

Additional Notes...