CONSULTATION FORM

Please fill out the form prior to your appointment. Forms are individual. If you have a spouse applying, you will need to fill out a separate form just for them.

Address Info

Do you have a separate mailing address?

PO Box or forwarding address is okay.

Please type the full mailing address including the city, state, and zip code.

Contact Info

Demographics

Gender*

Medicare Info

Do not enter spaces or dashes.
Do you have Part A & Part B?*

Doctors & Medical Providers

Think of any primary care doctors, specialist doctors, prior surgeons, or hospitals in the US. We need to look up all your providers to make sure they are in-network with whatever plan we review for you.

Prescriptions

Prescription drug coverage is only for U.S. pharmacies.

Other Coverage

Examples - VA, Tricare, ChampVA, employer or government, private. (If none, write "N/A"
Examples - Medicare Supplement (Medigap) plan (Plan F, G, N, etc.) or an Advantage plan (HMO, PPO, POS, etc) or a prescription Part D plan.
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