2021 OPEN ENROLLMENT

Play Tutorial

Play Tutorial

This year we are planning a stay safe enrollment with fewer meetings but more personal service. Click on the tutorial above to find out how.

Fillable Forms

Medicare Advantage Plan Review Form

Stand Alone Drug Plan Review Form

PDF Forms

Medicare Advantage Plan Review Form

Stand Alone Drug Plan Review Form

2021 Standalone Drug Plan Review Form

Enrollment Starts October 15, 2020
IMPORTANT: Medicare Open Enrollment Ends: December 7, 2020
To save print document or print as .pdf

Name*
Phone*
Street
City
State
Zip
Email*

Date of Birth
Date Format: MM slash DD slash YYYY

Your Pharmacy
Your Current Drug Plan

LIST OF MEDICATIONS
Please fill out the list of your current medications including: Name, dosage (mg), Number of Times Taken Per Day in order to get the drug review. Completing this form will not prevent you from enrolling into any plan of your choice for which you are eligible.

MEDICATIONS #1

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #2

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #3

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #4

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #5

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #6

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #7

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #8

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #9

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)

MEDICATIONS #10

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN

MEDICATIONS #11

NAME OF MEDICATION
BRAND
Brand
GENERIC
GENERIC
DOSAGE (MG)
NUMBER OF TIMES TAKEN
Per Day/Month/Year (Circle)
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the senior health advisor

1209 E Cumberland Ave #1903
Tempa, FL 33602

(813) 443-1154

betsy@theseniorhealthadvisor.com

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2021 Enrollment

© 2021 The Senior Health Advisor

2021 OPEN ENROLLMENT

This year we are planning a stay safe enrollment with fewer meetings but more personal service. Click on the tutorial above to find out how.

2021 Medicare Advantage Plan Review Form

Enrollment Starts October 15, 2020

Name of your doctor(s)

LIST OF MEDICATIONS

2021 Standalone Drug Plan Review Form

Enrollment Starts October 15, 2020

LIST OF MEDICATIONS

MEDICATIONS #1

MEDICATIONS #2

MEDICATIONS #3

MEDICATIONS #4

MEDICATIONS #5

MEDICATIONS #6

MEDICATIONS #7

MEDICATIONS #8

MEDICATIONS #9

MEDICATIONS #10

MEDICATIONS #11

the senior health advisor