Medicare Worksheet

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Instructions to complete and submit the worksheet:

Please use this worksheet to provide us with information about your current doctors and medications. If you need more time to get information about your doctors and medications, please remember to click on the "Safe Info" button from time to time to avoid losing the information you have already entered.

Click on the "Submit" button at the bottom of this screen once you have finished adding all the information in the form. The form submission will not be complete and we will not receive the information unless you click on the Submit button .

Select Agent:

Client Name:

Email:

Date of Birth:

Address:

City:

State:

Zip:

Phone:

Are you a Veteran?

Yes No

Are you currently eligible for Medicaid?:

Yes No

Authorized Representative Information (POA): Save Info

Name:

Relationship:

Address:

City:

State:

Zip:

Phone:

List of Current Doctors: Save Info

Doctor's Name:

Phone:

Doctor Type:

Address:

City:

State:

Zip:

Doctor's Name:

Phone:

Doctor Type:

Address:

City:

State:

Zip:

Doctor's Name:

Phone:

Doctor Type:

Address:

City:

State:

Zip:

Doctor's Name:

Phone:

Doctor Type:

Address:

City:

State:

Zip:

Doctor's Name:

Phone:

Doctor Type:

Address:

City:

State:

Zip:

Add New Row

List of Current Medications: Save Info

Name of Medication:

Med Type (Tab / Cap)

Dosage

X Per Day

Name of Medication:

Med Type (Tab / Cap)

Dosage

X Per Day

Name of Medication:

Med Type (Tab / Cap)

Dosage

X Per Day

Name of Medication:

Med Type (Tab / Cap)

Dosage

X Per Day

Name of Medication:

Med Type (Tab / Cap)

Dosage

X Per Day

Add New Row

Pharmacy Information: Save Info

Name:

Address:

City:

State:

Zip: