Questions? Give Us A Call At:

(405) 229-9544 - Sarah

(405) 905-9474 - Chris

Questions? Give Us A Call At:

(405) 229-9544 - Sarah

(405) 905-9474 - Chris

Schedule An Appointment

What's your Email?

How familiar are you with Medicare?

Not familiar

Somewhat familiar, but I don't know where to start

I have a pretty good idea

What's your name?

Perfect!

Let's Get Started.

Tell me about your current health insurance

(Check all that apply)

I'm already on Medicare

I have coverage through my employer/union

I have an individual plan through the marketplace

Original Medicare ( Medicare Part A, Medicare Part B, Medicare Parts A & B)

I'm on COBRA

I have Medicaid

I don't have health insurance

What's your address?

Great!

Now, we have a few questions that we will use to

provide plan options in your area.

What's your preferred pharmacy?

I Have No Preferred Pharmacy

Let's take a look at your current prescriptions.

Have your prescription bottles ready so we know which medications you take to include spelling, dosage and frequency

Please enter your current prescription medications:

Do not include over-the-counter medications, vitamins, supplements, or specialty drugs administered at your doctor's office or facility.

Enter N/A on prescription 1 only if you are not currently taking any medications

Prescription 1

Prescription 2

Prescription 3

Prescription 4

Prescription 5

Add more prescriptions if needed

Click Next if you have no additional prescriptions

Prescription 6

Prescription 7

Prescription 8

Prescription 9

Prescription 10

Add more prescriptions if needed

Click Next if you have no additional prescriptions

Prescription 11

Prescription 12

Prescription 13

Prescription 14

Prescription 15

Tell us about your Hospitals and Doctors

To provide plan options in your area, We'll need some info on your preferred hospitals and doctors to verify their network status

Do you have a preferred Hospital?

I Have No Preferred Hospital

Who is your Primary Cary Physician?

I don't have a primary care physician

Do you have a specialist?

(List all that apply)

I have no specialists

Tell us about your preferences when it comes to your Medicare Plan.

We will keep these in mind when providing options in your area.

Select which option best suits you:

I don't mind paying copays for medical services in exchange for lower monthly premiums

I would prefer to pay higher monthly premiums in exchange for little or no out-of-pocket costs for medical services

Do any of these apply to you?

Select all that apply:

We're almost done!

Just a few more questions before I can contact you

What is your phone number?

What is your age?

Let's wrap this up!

The Centers for Medicare and Medicaid Services (CMS) requires agents to document the scope of a marketing appointment prior to any face to face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary ( or their authorized representative). All infomation provided on this form is confidential and should be completed by each person with Medicare of his/her authorized representative.