2023 OPEN ENROLLMENT

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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

2023 Medicare Advantage Plan Review Form

Enrollment Starts October 15, 2022

IMPORTANT: Medicare Open Enrollment Ends: December 7, 2022

To save print document or print as .pdf

SPECIAL NOTE: Reviews are available if this form is complete including your list of medications. Return it to me by fax, email, or by mail in order to get a review. The best way to reach me is by email and not by phone in order to get the reviews back to you. The average drug savings is $300 to $2,000... It's worth completing the form. Please note: Completing this form will not prevent you form enrolling into any plan of your choice for which you are eligible.
Name*
Phone*
Street
City
State
Zip
Email*
Date of Birth
MM slash DD slash YYYY
Name of Current Plan
Did the drug plan meet your needs last year? (Please Check One)
- Yes
- No
If not, what needs to be improved?*
Did the medical plan meet your needs last year? (Please check One)
- Yes
- No
If not, what needs to be improved?*
Please look at the new changes for 2023 on your medical or drug plan. What changes give you concern?
Name of your pharmacy?
Will you mail order drugs? (Please Check One)
- Yes
- No
If you have medications, you would like me to review, please list them, the dosage, and frequency on the back of this form or include your list.

Name of your doctor(s)
DOCTOR'S NAME
SPECIALTY
CITY AND ZIP CODE
DOCTOR'S NAME
SPECIALTY
CITY AND ZIP CODE
DOCTOR'S NAME
SPECIALTY
CITY AND ZIP CODE
LIST OF MEDICATIONS
- NAME OF MEDICATION #1
  
  NAME OF MEDICATION #1
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #2
  
  NAME OF MEDICATION #2
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #3
  
  NAME OF MEDICATION #3
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #4
  
  NAME OF MEDICATION #4
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #5
  
  NAME OF MEDICATION #5
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #6
  
  NAME OF MEDICATION #6
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #7
  
  NAME OF MEDICATION #7
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #8
  
  NAME OF MEDICATION #8
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #9
  
  NAME OF MEDICATION #9
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #10
  
  NAME OF MEDICATION #10
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #11
  
  NAME OF MEDICATION #11
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
- NAME OF MEDICATION #12
  
  NAME OF MEDICATION #12
- DOSAGE (MG)
  DOSAGE (MG)
- NUMBER OF TIMES TAKEN
  NUMBER OF TIMES TAKEN
Please note that your information is held in private and all data is uniformly secured in accordance with the standards set forth in the Health Insurance Portability and Accountability Act.

STATEMENT AND REQUEST FOR CONTACT
I am making the express request for contact by my agent Elizabeth Vipond for her services in reviewing all plans available to me and do not wish to be limited to a review of my current plan.
NAME:
SIGNATURE:
DATE:
Month
Day
Year
CAPTCHA
Email
This field is for validation purposes and should be left unchanged.

2023 Standalone Drug Plan Review Form

Enrollment Starts October 15, 2022
IMPORTANT: Medicare Open Enrollment Ends: December 7, 2022
To save print document or print as .pdf

Name*

Phone*
Street

City

State

Zip
Email*

Date of Birth
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)
Signature

Date
Month
Day
Year

CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

the senior health advisor

1209 E Cumberland Ave #1903
Tempa, FL 33602

(813) 443-1154

betsy@theseniorhealthadvisor.com

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2023 Enrollment

© 2023 The Senior Health Advisor

2023 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.

2023 Medicare Advantage Plan Review Form

Enrollment Starts October 15, 2022

Name of your doctor(s)

LIST OF MEDICATIONS

2023 Standalone Drug Plan Review Form

Enrollment Starts October 15, 2022

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