Information Request - Current Clients

Click SUBMIT at the bottom when finished.

One person per form please

Place your information in the fields below.

First & Last Name (only one person per information request from please)

Multi-line address

Country/Region

Address

City

Zip / Postal code

County

Phone

When would you like your Medicare plan to change?

Do you have Medicaid provided by your state?

Yes

If YES to Medicaid, please enter your NYS Benefits ID number:

Which healthcare plan are you losing (Company & Plan Name)?

Are you a US Veteran?

PHYSICIANS

OPTIONAL: Upload a document listing ALL your physicans

List medical providers & specialties (skip if you have uploaded a file)

Primary Care Physician

List their specialty:

Primary Care Physician (PCP)

1 - DDS:

1 - List their specialty:

Dentist

2 - Doctor:

2 - List their specialty:

3 - Doctor:

3 - List their specialty:

4 - Doctor:

4 - List their specialty:

5 - Doctor:

5 - List their specialty:

6 - Doctor:

6 - List their specialty:

7 - Doctor:

7 - List their specialty:

List additional physicians and their specialty in the text field below

MEDICATIONS

Your preferred pharmacy name and location:

OPTIONAL: Upload a document listing ALL of your prescription medications.

List ONLY prescription medications, no Over-The-Counter (skip if you have uploaded a file)

1 - Drug name - enter NONE if no Rx

1 - Dose (mg, tab, ml, etc)

1 - How often?

2 - Drug name

2 - Dose

2 - How often?

3 - Drug name

3 - Dose

3 - How often?

4 - Drug name

4 - Dose

4 - How often?

5 - Drug name

5 - Dose

5 - How often?

6 - Drug name

6 - Dose

6 - How often?

7 - Drug name

7 - Dose

7 - How often?

8 - Drug name

8 - Dose

8 - How often?

9 - Drug name

9 - Dose

9 - How often?

List additional drugs, dose, and frequency of intake in the text field below

Do you spend time out of the area - total per year (so you will have coverage while away)?

Would you like your plan to have the following benefit options? (Check all that apply)

Additional comments:

Click the SUBMIT button above

After clicking the Submit button, watch for the onscreen "Thanks for submitting" message.