How To Get Started

Your Personalized Medicare Plan Analysis

Sharing this information with us is strictly voluntary. The information is used to create a more accurate
plan analysis based on your specific needs.

PLEASE NOTE: If you leave the page before submitting the form your progress will not be saved.

If you would prefer to download fillable forms click here

"*" indicates required fields

Scope of Sales Appointment Confirmation

The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting. Please initial below beside the type of product(s) you want the agent to discuss.

Sharing this information with us is strictly voluntary. The information is used to create a more accurate analysis based on your specific situation.

The person who will discuss the products is neither employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may be paid based on your enrollment in a plan.

Product Types to Discuss*

Stand-alone Medicare Prescription Drug Plans (Part D)

Medicare Advantage Plans (Part C) and Cost Plans

Dental/Vision/Hearing Products

Hospital Indemnity Products

Medicare Supplement (Medigap) Products

Check all that apply:

Your Initials*

Please provide your initials to confirm the products you want to discuss

Beneficiary or Authorized Representative Signature*

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you selected above. Signing this form does NOT obligate you to enroll in a plan.

Signature Date*

Representative's Name

Complete only if you are an authorized representative

Your Relationship to the Beneficiary

Complete only if you are an authorized representative

Personal Information

Please provide your personal and contact information

Name

First Last

Phone Number*

Date of Birth*

This field is hidden when viewing the form

Full Name*

Address*

Street Address Address Line 2 City State ZIP Code

County*

Email Address*

Tobacco Use in Last 12 Months?*

Yes

Marital Status*

Married

Single, Live Alone

Single, Live With Someone

Referred by

Current Health Coverage

Please provide information about your current health insurance coverage

Current Health Coverage Type

Individual

Employer

Retiree Plan

Drug Coverage Included?

Yes

Do you have an HSA (Health Savings Account)?

Yes

Plan Name

What is the plan name?

OR:

Medicare Advantage Plan Name

If you have Medicare Advantage, enter the plan name from your insurance card

OR:

Medicare Supplement Company Name

If you have Medicare Supplement, enter the company name from your insurance card

Medicare Supplement Plan Type

Enter the plan letter (F, G, etc.) from your insurance card

AND:

Current Prescription Drug Coverage Plan Name

Enter the plan name from your insurance card

Do you have Medicare Part A or B? (check the box if you do)

Part A

Part B

Are you a Veteran?

Yes

Interested in a Plan with Health Club Membership?

Yes

Mark here if you have a MEDICARE.gov account set up

Yes

Current Pharmacy Name

Healthcare Providers

Please provide information about your current healthcare providers so we can check if they accept various plans

Primary Care Doctor

Primary Care Doctor Phone

Dentist/Practice

Dentist Phone

Optometrist/Practice

Optometrist Phone

Specialist 1 - Type

Specialist 1 - Phone

Check to add More Doctors

Yes

This field is hidden when viewing the form

more doctors

Specialist 2 - Type

Specialist 2 - Phone

Specialist 3 - Type

Specialist 3 - Phone

Specialist 4 - Type

Specialist 4 - Phone

Specialist 5 - Type

Specialist 5- Phone

Specialist 6 - Type

Specialist 6- Phone

Specialist 7 - Type

Specialist 7- Phone

This field is hidden when viewing the form

Available Devices for Screen Share

PC/Laptop

Mac

iPad

iPhone

Android

None

We will utilize a screen share to review your analysis. Please mark ALL devices you have available:

Current Medications

Please provide information about your current medications. This helps us find the best prescription drug coverage for you.

Medication Status*

I take NO medications

I will provide my medication list below

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Current Medication List

Complete Drug Name (from bottle/container)

Dosage/Container Size

Form (Tab, Cap, Inhaler, Drops, Patch, Injection, Vial, Lotion, Cream, Ointment, Gel)

Quantity Per Refill

Refill Frequency (Monthly, Quarterly, Semi-Annually, Annually, Every 2 months)

Generic OK? (Yes/No)

Using GoodRx or discount plan? (Yes/No)

Please list each medication you currently take. You can add multiple rows.

IMPORTANT:

Please complete the medication list on the next page.

This will help ensure your Medicare plan covers all your prescriptions in the upcoming year. Fill in:

✔ Medication names
✔ Dosages
✔ How often you take them

Why? Comparing this list with your plan's 2025 formulary during Annual Enrollment (AEP) can help you avoid coverage gaps or extra costs.

Need help? Contact your plan or call Medicare at 1-800-MEDICARE (1-800-633-4227).

Pro tip: Keep a copy for your records and doctor visits.

Additional Notes

Please provide any additional information that might be helpful for your personalized Medicare Plan Analysis.

Scope of Sales Appointment Confirmation

Personal Information

Current Health Coverage

Healthcare Providers

more doctors

Current Medications

Please complete the medication list on the next page.

Find Your Perfect Medicare Plan

Jenell Sobas, FPQP®