Medicare Planning Review Request

First Name

Last Name

Primary Phone

Secondary Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

What county do you live in?

Date of Birth

Would 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 member

Additional Family Member Name:

First Name

Last Name

Date of Birth

Provide Information Below for

When will you need your Medicare coverage to start?

Are you a Veteran?

Yes

Do you use the VA for your prescriptions?

Yes

Not now, but would consider

I choose NOT to use the VA

Who 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

Will you consider mail order?

Do You Take Any Prescribed Medications?

Yes

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

Who are your Specialists?

Specialist Name	Area of Specialty

What 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 Form

Before meeting with a Medicare beneficiary (or their authorized representative), Medicare requires that Licenses 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 Products

By 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 Date

To 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 Completed
TBD

Initial Method of Contact
TBD

Plan(s) the Licensed Sales Representative will represent during the meeting
MAPD, Med Supp, Part D

Licensed Sales Representative Signature
Individual Health Solutions, LLC

*Scope of Appointment documentation is subject to CMS record retention requirements*

Provide Information Below for

When will you need your Medicare coverage to start?

Are you a Veteran?

Yes

Do you use the VA for your prescriptions?

Yes

Not now, but would consider

I choose NOT to use the VA

Who 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

Will you consider mail order?

Do You Take Any Prescribed Medications?

Yes

Name of Medication	Medication Form	Dosage/Strength	Quantity Per Month

Who are your Specialists?

Specialist Name	Area of Specialty

What 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 Form

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 Products

Beneficiary or Authorized Representative Signature

Sign Here

Signature Date

To 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 Completed
TBD

Initial Method of Contact
TBD

Plan(s) the Licensed Sales Representative will represent during the meeting
MAPD, 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.

Medicare Planning Review Request

Additional Family Member Name:

Provide Information Below for

Scope of Appointment Confirmation Form

To be Completed by the Licensed Sales Representative:

Provide Information Below for

Scope of Appointment Confirmation Form

To be Completed by the Licensed Sales Representative:

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