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Let's Get to Know You

Date/Time
:  
Name*
Address*
Gender
Date of Birth

Where Do You Stand?

1. Current Health Insurance:
2. Once I turn 65, I plan to:
3. Are you currently receiving Social Security Benefits?
4. Do any of these apply to you? (Click all that apply)

Medicare Plan Wishlist

Please check all the statements below that apply to you and your preferences (Click all that apply)

Prescription & Pharmacy Information

example - CVS, Meijer, Mail Order, etc
example - CVS, Meijer, Mail Order, etc
example - CVS, Meijer, Mail Order, etc

Prescriptions 1-5

example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily

Prescriptions 6-10

example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily

Prescriptions 11-15

example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily

Prescriptions 16-20

example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily

Prescriptions 21-25

example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily
example - Atorvastatin
Generic
example - 10mg 2 times daily


Hospital & Physicians

example - Riverside Hospital; The James; Cleveland Clinic
example - Riverside Hospital; The James; Cleveland Clinic
example - Riverside Hospital; The James; Cleveland Clinic
example - Dr. John Doe / Columbus, OH
Check here if you do not currently have a Primary Care Physician (PCP)
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist; Cardiologist; Dermatologist
First and Last Name
Location
Neurologist, Cardiologist, Dermatologist

Additional Information

In order for a Seniority Benefit Group Benefit Advisor to complete a full analysis and make any recommendations, CMS requires you, as the Medicare Beneficiary, to complete the below Scope of Appointment Form to authorize an Advisor to speak to you regarding Medicare Plans.



Scope of Sales Appointment Confirmation Form


The Centers for Medicare and Medicaid Services 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 information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.


Please initial below beside the type of product(s) you want the agent to discuss.


Initials

Medicare Prescription Drug Plan (PDP) - A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

Initials

Medicare Health Maintenance Organization (HMO) - A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. In most HMOs, you can only network (except in emergencies). 

Medicare Preferred Provider Organization (PPO) Plan - A Medicare Advantage Plan that provides all Original Medicare Part A and Part B health coverage and sometimes covers Part D prescription drug coverage. PPOs have network doctors and hospitals but you can also use out-of-network providers, usually at a higher cost.

Medicare Private Fee-For-Service (PFFS) Plan -  A Medicare Advantage Plan in which you may go to any Medicare-approved doctor conditions and agrees to treat you not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers. 

Medicare Special Needs Plan (SNP) -  A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions. 

Medicare Medical Savings Account (MSA) Plan - MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met. 

Medicare Cost Plan - In a Medicare Cost Plan, you can go to providers both in and out of network-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles.

Initials

Medicare Supplement (Medigap) Plan - Plans offering a supplemental policy to fill “gaps” in Original Medicare coverage. A Medigap policy typically pays some or all of the deductible and coinsurance amounts applicable to Medicare-covered services, and sometimes covers items and services that are not covered by Medicare, such as care outside of the country. These plans are not affiliated or connected to Medicare.

Initials

Dental/Vision/Hearing Products - Plans offering additional benefits for consumers who are looking to cover needs for dental, vision or hearing. These plans are not affiliated or connected to Medicare.

Use your mouse (or finger if on a tablet or mobile device) to draw your signature above

Confirmation Page

By submitting this form, you acknowledge that you understand this is a solicitation for insurance. When available, we offer Medicare Supplement, Medicare Advantage and Part D plans from a number of insurance carriers. A Seniority Benefit Group, Inc., licensed insurance agent may contact you. Seniority Benefit Group, Inc., is not connected with or endorsed by the U.S. Government or the federal Medicare program. Individual products and features are subject to availability and may vary by state.

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