Test - Step 1 of 9 Please fill out one form for each person and submit it to us.Name *FirstLastEmail *PhoneNextList the names of the doctors and clinics you use and must keep. NextEstimate the number of annual visits for 2019 to the following:Doctors/Specialists1234567891011121314151617181920Labs/ Physical therapy / Mental health / other on-going monthly or quarterly Treatments11234567891011121314151617181920NextList any upcoming major procedures, treatments or surgeries expected for 2019NextDo you use Durable Medical Equipment, like sleep apnea, prosthetics, oxygen, etc.?YesNoIs there a chronic disease or condition we should be aware of?YesNoNextPlease rank the following extra benefits using a scale of 1-5, with 1 being the most important to you.Routine Dental12345Travel Coverage12345Coverage for Glasses or Hearing Aids 12345Fitness Gym Benefit 12345Sliver & Fit or Silver Sneakers12345NextAre you a Snow Bird?-----YesNoNextOther conditions, services or concerns about your coverage not mentioned?-----YesNoMedicare Prescription Drug Plan Information Current Drug Rx Plan?CheckboxesBlue CrossHealth PartnersHumanaMedicaSilver ScriptOther Drug PlanAre you happy with it?-----YesNoList current medications below or send a copy of your current medications by clicking the choose file button below.Send a copy of current medicationsAny additional information:EmailSubmit
