Health Information Form

Use this secure e-form to submit information about your doctors and medications, so we can prepare for your appointment. This helps us do a better job of reviewing your insurance options.

We are dedicated to protecting your private information. Your information will not be distributed, disclosed or sold to any outside parties. Privacy Policy

Name

First Name

Last Name

Phone

(###)

###

####

Email

Describe your situation and how we can help

List your current doctors & specialists

List your preferred hospital(s) and facilities

List your prescription drugs, frequency, and dosages

Do you travel, and if so where?

Do you receive help for paying for medications?

Yes

No

Unsure

Do You Qualify for Medicaid?

Yes

No

Unsure

Do You Receive VA Benefits?

Yes

No

Unsure

I understand by submitting the form above I may be contacted by a licensed insurance professional to discuss options including Medicare Advantage Plans, Medicare Supplement Plans, and Part D Drug Plans. I may revoke this consent at any time. Use of this service is not contingent on purchase.