About you

We ask for all of these so Barb can match this form to your record without having to ring you.

First name

Last name

Date of birth

ZIP code

Phone

Best way to contact you

PhoneTextEmailAny

1.) How do you feel about your current plan?

Want to stay with the plan. Please don't do anything. (no need to fill out the scope)Like the plan but let me know if there might be sometime better.Definitely want to change plans.

Main reason you want to change plans

2.) Complete the list of medications

People usually remember to tell me all their prescription tablets and capsules but often forget to include things like their insulin, nasal sprays, asthma inhalers, creams, and ointments.

DON'T include medications that are otc (over the counter) or you get at the VA or that Worker's Comp pays for.

Medicine 1

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 2

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 3

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 4

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 5

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 6

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 7

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 8

Drug

Strength

Form (tab, cap, spray etc)

How often

Medicine 9

Drug

Strength

Form (tab, cap, spray etc)

How often

Preferred Pharmacy

3.) Do you receive Extra Help for your prescriptions:

YesNoI’m not sure

Doctors that you simply MUST HAVE in your plan:

Doctor 1

First and Last Name

Phone number

City and Zip code

Doctor 2

First and Last Name

Phone number

City and Zip code

Doctor 3

First and Last Name

Phone number

City and Zip code

Doctor 4

First and Last Name

Phone number

City and Zip code

Doctor 5

First and Last Name

Phone number

City and Zip code

Additional comments:

Stuck? Call Barb on (216) 287-8832.

Medicare Advantage questions

About you

1.) How do you feel about your current plan?

2.) Complete the list of medications

3.) Do you receive Extra Help for your prescriptions:

Doctors that you simply MUST HAVE in your plan: