Medicare Scope of Appointment Form Request

Comments

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

Scheduled Date of Meeting(Required)

Please enter the date of your appointment. A date of at least 48hrs in the future is required. If you haven't scheduled an appointment yet, please contact us to schedule before submitting this form.

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please select the type of product(s) you wish to discuss with your Advisor(Required)

By selecting product options, you are giving your Advisor Medicare required permission to speak to you about these products. The Advisor is not allowed to speak about any product not selected. Selecting products for discussion does not require a discussion, just the allowance to discuss the product if the topic should arise.

Stand-Alone Medicare Prescription Drug Plans (Part D)

Medicare Advantage Plans (Part C)

Dental/Vision/Hearing Products

Hospital Indemnity Products

Medicare Supplement (Medigap) Products

To assist with shopping coverage options, we typically like to make sure any necessary providers and/or prescriptions are covered. Would you like assistance with shopping your coverage options?(Required)

Yes

No

Provider List

If you are shopping medical coverage with provider network considerations, please enter the providers you wish to have in-network. To add more providers, click the + icon at the end (on the right) of the previous provider entry.

Provider First Name

Provider Last Name

Dr. type, if known (MD, DO, DDS, etc.)

Group Affiliation, if known (Everett Clinic, Multicare, etc.)

Provider List

If you are shopping medical coverage with provider network considerations, please enter the providers you wish to have in-network. To add more providers, click the + icon at the end (on the right) of the previous provider entry.

Provider First Name

Provider Last Name

Dr. type, if known (MD, DO, DDS, etc.)

Group Affiliation, if known (Everett Clinic, Multicare, etc.)

Provider List

If you are shopping medical coverage with provider network considerations, please enter the providers you wish to have in-network. To add more providers, click the + icon at the end (on the right) of the previous provider entry.

Provider First Name

Provider Last Name

Dr. type, if known (MD, DO, DDS, etc.)

Group Affiliation, if known (Everett Clinic, Multicare, etc.)

Prescription List

Please enter your prescription list if you are shopping coverage that includes prescription coverage, excluding any over the counter supplements, etc. To add more prescriptions, click the + icon at the end (on the right) of the previous prescription entry.

Drug Name (ex: Lisinopril)

Dosage (ex: 10mg)

Frequency (ex: 1x daily)

Prescription List

Please enter your prescription list if you are shopping coverage that includes prescription coverage, excluding any over the counter supplements, etc. To add more prescriptions, click the + icon at the end (on the right) of the previous prescription entry.

Drug Name (ex: Lisinopril)

Dosage (ex: 10mg)

Frequency (ex: 1x daily)

Prescription List

Please enter your prescription list if you are shopping coverage that includes prescription coverage, excluding any over the counter supplements, etc. To add more prescriptions, click the + icon at the end (on the right) of the previous prescription entry.

Drug Name (ex: Lisinopril)

Dosage (ex: 10mg)

Frequency (ex: 1x daily)

Preferred Pharmacy

Local Pharmacy

Are there any local pharmacies you would like in-network (in case of an emergency)?

Name of Preferred Pharmacy

Additional Info/Questions/Comments/Notes

Please provide us with any other information that may help, otherwise click the NEXT button below.

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Electronic Scope of Appointment Request