Information Request - New Clients

Click the SUBMIT button at the bottom of this page when finished. - Thank you.

One person per form please

Place your information in the fields below.

First & Last Name

Multi-line address

Country/Region

Address

City

Zip / Postal code

County

Phone

Date of Birth:

Month

Day

Year

Medicare Part A & Part B:

Select the month you would you like your Medicare plan to start?

Month

Day

Year

Are you currently enrolled in your state's Medicaid program?

Yes

If you have Medicaid, please enter your NYS Benefits ID number (8 digits)

Are you a US Veteran?

Name of your current insurance company and plan name that have now (list NONE if n/a)

Is your current insurance through a retiree or union group?

PHYSICIANS

CHECK THIS BOX if you are uploading a PDF, MS Word, or text document listing ALL of your physicans in the section below.

Click to upload list of your physicians (optional for your convenience).

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:

CHECK THIS BOX if you are uploading a PDF, MS Word, or text document listing ALL of your medications in the section below.

Click to upload a list of your medications (optional for your convenience).

List ONLY prescription medications, no over-the-counter (skip this section 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 & if you have Medicaid, enter your ID number below:

Click the SUBMIT button above when you are finished.

Thank you!