Medicare Profile Form

To provide you with the most suitable Medicare plans, please complete the form below. Include your doctors, medications, and pharmacy preference so we can find the best fit for you.

First Name *

Last Name *

D.O.B. *

Email *

Phone *

Address *

Preferred Pharmacy *

Referred By

Please note we are only able to discuss Medicare plans with the above beneficiary unless you have a Power of Attorney.

Please check this box if you have a Power of Attorney (POA)Please check this box if you would like additional information on dental, vision, long term care or life insurance

Government regulations require us to wait 48 hours after you sign a Scope of Appointment, however if you have a time sensitive issue, please bring that to our attention.

Medication & Dosage

Doctors

Additional Information (optional file)

PDF or photo, up to 8 MB.

If currently enrolled in a Medicare Advantage or a Supplemental plan, include the insurance carrier's plan name here:

If you are a current member of AARP please provide the AARP membership number:

If you have MEDICAID, please provide your MEDICAID number:

Scope of Sales Appointment Confirmation Form

The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

Please mark beside the type of product(s) you want the agent to discuss

Medicare Advantage Prescription Drug Plans (Part C) and Cost Plans

Medicare Preferred Provider Organization (PPO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and includes Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.Medicare Health Maintenance Organization (HMO) Plan — A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and includes Part D prescription drug coverage. With most HMOs, you can only get your care from doctors or hospitals in the plan's network (except in emergencies).

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Prescription Drug Plan (PDP) — A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Additional Products

Dental/VisionMedicare Supplement (Medigap) Products

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above.

Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

Signature *

Sign with your mouse or finger.