Advisors Form

Name*

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Zip Code*

Advisor's Name*

Preferred Method of Contact*

Email
Phone

Phone

Email

Prescription Drug Update

Please enter your current prescriptions. Brand name drugs can differ in costs from generic. Please only enter the brand name if you cannot take the generic version. It’s helpful for your advisor to know your specific drug information to accurately research drug costs for plans in your service area. For assistance, call 877-996-3364.

List Presecription Drugs

Please enter each prescription drug, strength(mg), Daily dosage and also note the type and quantity per month.

Preferred Retail Pharmacy Name

Second Choice

Do you use mail order or interested in Mail order?

Yes
No

Do you prefer 30-day or 90-day prescription refills?

30 day
90 day

What is the name of your current Prescription plan?

For new clients and those on a Medicare Advantage Plan ONLY:

Doctor List - Primary Care, all specialists, dentist, vision:

List each doctor's name, specialty and City located in.

Current Medicare Advantage Plan

Are you happy with your plan?

Comments?

Appointment Preference

Appointment Preference You Prefer?

Preferred Day

Please note any dates you may not be available to meet during October 15thand December 7th

Consent*

By submitting this form, you agree to be contacted via phone and/or email by a licensed insurance agent of Medicare Advisors of Ohio.

I Agree

Name

This field is for validation purposes and should be left unchanged.

Prescription Drug Update

For new clients and those on a Medicare Advantage Plan ONLY:

Appointment Preference

(877) 996-3364 (TTY: 711)

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