Medicare Planning Review Request Medicare Planning Review Request First NameLast NameGenderEmailPrimary PhoneSecondary PhoneAddressAddress Line 1Address Line 2CityStateZip CodeWhat county do you live in?- Select -Adams CountyAshland CountyBarron CountyBayfield CountyBrown CountyBuffalo CountyBurnett CountyCalumet CountyChippewa CountyClark CountyColumbia CountyCrawford CountyDane CountyDodge CountyDoor CountyDouglas CountyDunn CountyEau Claire CountyFlorence CountyFond du Lac CountyForest CountyGrant CountyGreen CountyGreen Lake CountyIowa CountyIron CountyJackson CountyJefferson CountyJuneau CountyKenosha CountyKewaunee CountyLa Crosse CountyLafayette CountyLanglade CountyLincoln CountyManitowoc CountyMarathon CountyMarinette CountyMarquette CountyMenominee CountyMilwaukee CountyMonroe CountyOconto CountyOneida CountyOutagamie CountyOzaukee CountyPepin CountyPierce CountyPolk CountyPortage CountyPrice CountyRacine CountyRichland CountyRock CountyRusk CountySt. Croix CountySauk CountySawyer CountyShawano CountySheboygan CountyTaylor CountyTrempealeau CountyVernon CountyVilas CountyWalworth CountyWashburn CountyWashington CountyWaukesha CountyWaupaca CountyWaushara CountyWinnebago CountyWood CountyDate of BirthWould you like to meet with a specific agent?Are you completing this form for you only — or for you and an additional family member? Me only Me and an additional family memberAdditional Family Member Name:First NameLast NameGenderDate of BirthPreviousNextProvide Information Below for When will you need your Medicare coverage to start?Are you a Veteran? Yes NoDo you use the VA for your prescriptions? Yes No Not now, but would consider I choose NOT to use the VAWho is your current Primary Care Physician? Pharmacy Preferences (please enter multiple options, unless you will ONLY go to one pharmacy even if it costs more). Pharmacy Name Preference Level 1st Choice2nd Choice3rd ChoiceIf 1st option isn't good, then I am flexibleI will pay more for this optionI never want to go here Will you consider mail order?- Select -Yes — I already useYes — I would considerNo — I would not considerMaybe — if cost savingsDo You Take Any Prescribed Medications? Yes No Please enter ALL your prescriptions here. Use your bottle/container for reference. Include ALL details (XR, ER, etc.), pens, 2 inhalers per year, etc.) If you are on INSULIN, indicate the number of boxes of pens or vials you need per month. DO NOT give us units of insulin. Be as specific as possible - seemingly small differences can make a huge price difference. Put details in the box provided later in the form if you have questions. Name of Medication Medication Form Dosage/Strength Quantity Per Month TabletCapsuleBox of PensVialCreamGelOintmentLotionInhalerOther Who are your Specialists? Specialist Name Area of Specialty What provider systems are important to you? Select any that apply. Ascension Aurora Froedert ProHealth UW Health OtherWhat other provider system(s) are important to you?Who is your current dentist?Please provide any additional details you think might be helpful here — details are helpful! Or if you have questions or want to clarify any information, this is the place!Scope of Appointment Confirmation FormBefore meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary.Please check what you want to discuss with the Licensed Sales Representative. Medicare Advantage Plans (Part C) and Cost Plans Stand-alone Medicare Prescription Drug Plan (Part D) Medicare Supplement (Medigap) Plan Dental-Vision-Hearing Products Hospital Indemnity ProductsBy signing this form, you agree to meet with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential. Beneficiary or Authorized Representative Signature Sign Here Signature DateTo be Completed by the Licensed Sales Representative:Licensed Sales Representative Name:A licensed representative of Individual Health Solutions Licensed Sales Representative Phone:272-714-0045 Licensed Sales Representative ID:17417406 Name Phone Date Appointment will be CompletedTBD Initial Method of ContactTBD Plan(s) the Licensed Sales Representative will represent during the meetingMAPD, Med Supp, Part D Licensed Sales Representative SignatureIndividual Health Solutions, LLC*Scope of Appointment documentation is subject to CMS record retention requirements*PreviousNextProvide Information Below for When will you need your Medicare coverage to start?Are you a Veteran? Yes NoDo you use the VA for your prescriptions? Yes No Not now, but would consider I choose NOT to use the VAWho is your current Primary Care Physician? Pharmacy Preferences (please enter multiple options, unless you will ONLY go to one pharmacy even if it costs more). Pharmacy Name Preference Level 1st Choice2nd Choice3rd ChoiceIf 1st option isn't good, then I am flexibleI will pay more for this optionI never want to go here Will you consider mail order?- Select -Yes — I already useYes — I would considerNo — I would not considerMaybe — if cost savingsDo You Take Any Prescribed Medications? Yes No Please enter ALL your prescriptions here. Use your bottle/container for reference. Include ALL details (XR, ER, etc.), pens, 2 inhalers per year, etc.) If you are on INSULIN, indicate the number of boxes of pens or vials you need per month. DO NOT give us units of insulin. Be as specific as possible - seemingly small differences can make a huge price difference. Put details in the box provided later in the form if you have questions. Name of Medication Medication Form Dosage/Strength Quantity Per Month TabletCapsuleBox of PensVialCreamGelOintmentLotionInhalerOther Who are your Specialists? Specialist Name Area of Specialty What provider systems are important to you? Select any that apply. Ascension Aurora Froedert ProHealth UW Health OtherWhat other provider system(s) are important to you?Who is your current dentist?Please provide any additional details you think might be helpful here — details are helpful! Or if you have questions or want to clarify any information, this is the place!Scope of Appointment Confirmation FormBefore meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licensed Sales Representatives use this form to ensure your appointment focuses only on the type of plan and products you are interested in. A separate form should be used for each Medicare beneficiary.Please check what you want to discuss with the Licensed Sales Representative. Medicare Advantage Plans (Part C) and Cost Plans Stand-alone Medicare Prescription Drug Plan (Part D) Medicare Supplement (Medigap) Plan Dental-Vision-Hearing Products Hospital Indemnity ProductsBy signing this form, you agree to meet with a Licensed Sales Representative to discuss the products checked above. The Licensed Sales Representative is either employed or contracted by a Medicare plan and may be paid based on your enrollment in a plan. They do not work directly for the federal government. Signing this form does not affect your current or future enrollment in a Medicare plan, enroll you in a Medicare plan or obligate you to enroll in a Medicare plan. All information provided on this form is confidential. Beneficiary or Authorized Representative Signature Sign Here Signature DateTo be Completed by the Licensed Sales Representative:Licensed Sales Representative Name:A licensed representative of Individual Health Solutions Licensed Sales Representative Phone:272-714-0045 Licensed Sales Representative ID:17417406 Name Phone Date Appointment will be CompletedTBD Initial Method of ContactTBD Plan(s) the Licensed Sales Representative will represent during the meetingMAPD, Med Supp, Part D Licensed Sales Representative Signature *Scope of Appointment documentation is subject to CMS record retention requirements* I consent to have this website store my submitted information so Individual Health Solutions can respond to my Medicare planning review request. Previous Submit Form
