EmailMeForm
Name
*
Email
*
Phone #
*
Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
Are you a Veteran?
Yes
No
Medicare Questions
Date of Birth
What Part of Medicare Do You Have
Part A
Part B
What Is Your Part A Effective Date
What Is Your Part B Effective Date
Name (as it appears on your Medicare card)
Medicare Number
What Plan Type Do You Have
Supplement
Medicare Advantage
Part D (Prescription)
What Is The Name of Your Part D Insurance Company?
What is the effective date?
If not eligible, date of eligibility
Medicaid,DUAL or LIS?
What is the effective date?
Do You Travel? In USA, Internationally?
If so for how long?
What benefits would you like to see on your plan?
Current Health Insurance Plan:
Coverage Type:
Company
Plan Type
End Date
What is Your Preferred Pharmacy?
RX Drug Search
Drug Name
Dosage (MG Amount)
Times Per Day
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Provider Search
First Name
Last Name
Speciality
City
Zipcode
Primary Care 1
Specialist 2
Specialist 3
Specialist 4
Specialist 5
Diabetic Supplies
Yes
No
Hearing Aids?
Yes
No
Durable Medical Equipment:
Oxygen?
Wheelchair?
Walker?
Other?
Chronic Illness?
Questions, comments additional medications
By completing this form you agree that, Gary Bartick, licensed insurance agent, may contact you by phone or email to answer any questions you have regarding Medicare Advantage Plans, Medicare Supplement Insurance, and/or Prescription Drug Plans.
