Medicare Advantage Plan Review Form Enrollment Starts October 14, 2020IMPORTANT: Medicare Open Enrollment Ends: December 7, 2020 CompanyThis field is for validation purposes and should be left unchanged.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*StreetCityStateZipEmail* Date of Birth MM slash DD slash YYYY Name of Current PlanDid 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 NAMESPECIALTYCITY AND ZIP CODEDOCTOR'S NAMESPECIALTYCITY AND ZIP CODEDOCTOR'S NAMESPECIALTYCITY AND ZIP CODELIST OF MEDICATIONSNAME OF MEDICATION #1NAME OF MEDICATION #1BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #2NAME OF MEDICATION #2BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #3NAME OF MEDICATION #3BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #4NAME OF MEDICATION #4BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #5NAME OF MEDICATION #5BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #6NAME OF MEDICATION #6BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #7NAME OF MEDICATION #7BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #8NAME OF MEDICATION #8BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #9NAME OF MEDICATION #9BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #10NAME OF MEDICATION #10BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #11NAME OF MEDICATION #11BRANDGENERICDOSAGE (MG)DOSAGE (MG)NUMBER OF TIMES TAKENNUMBER OF TIMES TAKENPer DayMonthYearNAME OF MEDICATION #12NAME 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 CAPTCHA
