2024 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. 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 Scope of Appointment Sign and Date Only 2024 Medicare Advantage Plan Review Form Enrollment Starts October 15, 2023IMPORTANT: Medicare Open Enrollment Ends: December 7, 2023To 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 ZipEmail* 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 MEDICATIONSNAME OF MEDICATION #1 NAME OF MEDICATION #1BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #2 NAME OF MEDICATION #2BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #3 NAME OF MEDICATION #3BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #4 NAME OF MEDICATION #4BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #5 NAME OF MEDICATION #5BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #6 NAME OF MEDICATION #6BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #7 NAME OF MEDICATION #7BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #8 NAME OF MEDICATION #8BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #9 NAME OF MEDICATION #9BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #10 NAME OF MEDICATION #10BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #11 NAME OF MEDICATION #11BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #12 NAME OF MEDICATION #12BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearPlease 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 CAPTCHAEmailThis field is for validation purposes and should be left unchanged. 2024 Standalone Drug Plan Review Form Enrollment Starts October 15, 2023IMPORTANT: Medicare Open Enrollment Ends: December 7, 2023To save print document or print as .pdf Name* Phone*Street City State ZipEmail* 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)SignatureDate Month Day Year CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
