My doctors & medications

Add your doctors and prescriptions so we can make sure your plan covers them. It only takes a few minutes.

Your information

Full nameHome addressPhoneEmail (optional)

Doctors & specialists

Type of doctorDoctor's last name

No doctors added yet.

Prescriptions

Medication name

No medications added yet.

Anything else? (optional)

Scope of Appointment

Check the type(s) of product you want the agent to discuss:

Stand-alone Medicare Prescription Drug Plans (Part D)Medicare Advantage Plans (Part C) and Cost PlansDental/Vision/Hearing ProductsHospital Indemnity ProductsMedicare Supplement (Medigap) Products

By signing this form, you agree to a meeting with a sales agent to discuss the types of products you checked above. The person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

Sign

Type your full name as your signature

Signing for someone else? (authorized representative)

Representative's nameRelationship to the beneficiary

I agree that typing my name above is my electronic signature on the Scope of Appointment.