Medicare Plan Review Intake

Tell us your doctors, prescriptions, pharmacy, and hospital preferences so we can review your Medicare options more accurately.

Please do not enter your Social Security number, banking information, or payment information on this form.

1. Your information
2. Medicare details
3. Doctors and medicine
4. Consent

Client Information

First Name *

Last Name *

Phone *

Email *

ZIP Code *

County

State

Current Medicare Situation

Current coverage type

Insurance company/plan name

Part A effective date

Part B effective date

Medicare number (optional) Enter the Medicare number shown on your red, white, and blue Medicare card. This is different from your Medicaid number or your insurance plan member ID. Leave blank if you prefer to provide it directly to Mike.

Medicaid number (if applicable) If you have Medicaid, enter your Medicaid member/recipient number as shown on your state Medicaid card. This is different from your Medicare number. Leave blank if you do not have Medicaid or do not have the number handy.

What would you like reviewed?

Medicare Advantage

Medicare Supplement

Part D drug coverage

Not sure

Doctors

Add doctors you want checked, or mark that you do not have any to list right now.

I do not have any doctors to list right now.

Hospital Preferences

Optional: If you do not have a preferred hospital, you can leave this section blank.

Preferred hospital

Backup hospital

Important to keep in-network?

Hospital notes

Medications

Start typing a medicine name for spelling suggestions, or mark that you do not take any prescription medications right now.

I do not take any prescription medications right now.

Pharmacy Preferences

Optional: If you have a preferred pharmacy, list it here. This can help with Part D or Medicare Advantage prescription drug reviews.

Preferred pharmacy name

Pharmacy city/ZIP

Open to mail-order?

Other Notes

Anything else you want us to know before your Medicare review?

I authorize Your Insurance Coach to use the information I submit to help compare Medicare coverage options and contact me about my Medicare review. *

I understand this is not an application for insurance and I may be asked to complete a Scope of Appointment before discussing specific Medicare Advantage or Part D plan options, if required. *

I agree to receive text messages from Your Insurance Coach about my Medicare review at the phone number provided. Message and data rates may apply. Message frequency may vary. Reply STOP to opt out or HELP for help. Consent is not a condition of purchase.