Your 

Medicare PLanning

Plan




When did you need your new Medicare coverage to take effect? (Medicare plans all take effect on the 1st day of the month)*

Do you currently have Medicare Parts A & B?*

Please check all that apply to you*






Please list your Primary Care Doctor and the city and state in which they practice. If you do not have a Primary Care Doctor, please enter "none".*

Do you intend to continue using this doctor in the future?*


Please list the full name and city of any specialists you see.

Please list all medications you currently take including frequency and dosage.*

Are you interested in plans that provide optional benefits such as dental (preventative and comprehensive), vision (exams and eyewear) and hearing (exams and hearing aids)?*

Do you occasionally travel outside the United States?*

Please rank the

Please rank the following attributes in terms of importance to you*

 
Very
Important
Somewhat
Important
Neutral
Not Very
Important
Not
Important
At All
Having no out-of-pocket costs
Low monthly premium
Low co-pays
Cost of medications
Flexibility in choosing my doctors
Extra benefits such as dental, vision and hearing, health club membership
Quality rating of plan
Focus on preventative and health


Do you receive extra assistance from the government for your health care costs?


Do you have any special health needs or conditions? (This is entirely optional and you are within your HIPAA rights not to disclose this information. If you do choose to disclose this information, it will only be used to assist you in identifying and understanding Medicare plan options available to you based on your unique needs).

Is there any other information we should consider when evaluating your Medical options?

First Name*

Last Name*

In what city and state do you live?*

Please provide the best phone number to contact you*

Please provide your e-mail for us to send your Medicare Recommendations Report*


 
Very
Important
Somewhat
Important
Neutral
Not Very
Important
Not
Important
At All
Having no out-of-pocket costs
Low monthly premium
Low co-pays
Cost of medications
Flexibility in choosing my doctors
Extra benefits such as dental, vision and hearing, health club membership
Quality rating of plan
Focus on preventative and health

Medicare Needs Worksheet

Thank you for allowing us to assist you with your Medicare needs. Medicare is not a "one-size fits all" product, that is why we represent all of the major carriers for Medicare Supplements, Medicare Advantage and Medicare Part D Drug Plans.In order to assist us in identifying the best Medicare options from which you will choose, please complete the following information. We will reply with your Medicare Recommendations Report. This information will remain confidential and will only be used to assist you in identifying and understanding your Medicare options. In the meantime, please feel free to call us at 1-(800) 945-1953 or e-mail us at info@yourmedicareplanning.com.


* Denotes Required