Please complete the information below to help us provide 2011 Medicare options for you. This information will be kept completely confidential.

Your Name
Date of Birth
Gender
Email
Mailing Address
City
State
Zip Code
County
Home Phone
Cell Phone
 
Please list your perferred physicians, including the office address.
 
Name (First & Last) # visits/year
 
Office Address Phone #
 
Name (First & Last) # visits/year
 
Office Address Phone #
 
Name (First & Last) # visits/year
 
Office Address Phone #
 
Name (First & Last) # visits/year
 
Office Address Phone #
 
Your preferred hospital
How many times were you admitted to the hospital in the past 12 months?
Total Days?
 
Please list all of your current prescription medications, including generics.
Example: RX Name   Coumadin   (G)   Dosage   5mg  How often  1 a day
If you take injectables/inhalers please list the number of vials/inhalers you use per month.
 
Rx Name Dosage How Often
Rx Name Dosage How Often
Rx Name Dosage How Often
Rx Name Dosage How Often
Rx Name Dosage How Often

 

How many weeks a year are you out of your home
state?
What states do you travel to?
Do you have any specific requirements for us to consider?
How did you hear about us?

 

Authorization- I have willingly provided the health information on this page to McGohan Brabender Senior Solutions (MBSS) to assist me in my selection of an individual health plan for 2010. I am seeking their recommendation for a Medicare plan that will meet my needs. After MBSS completes their review, I authorize them to contact me by phone or mail to schedule a personal consultation at no cost to me. Prior to any individual sales meeting with a licensed agent, I am aware that I will need to complete and sign a Scope Of Appointment form which will specify the types of health plans that I am interested in and they can discuss with me.

The information I have provided to MBSS on this form is not to be used for any purpose other than my Medicare health plan selection. I understand that I am not bound to accept their recommendation.


 

 
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