Find which Medicare Advantage plan works best for you

Contact Information: (We Service Connecticut Residents Only)                          

Name                                                                                  
Address Street
Town/City Zip Code (Connecticut Only)
Date of Birth (mm/dd/yyyy)
Gender Male Female
Email Address
Phone Number Extension
When will you need coverage to begin? 01/01/2012 02/01/2012 03/01/2012 04/01/2012 05/01/2112 06/01/2012 07/01/2012 08/01/2012 09/01/2012 10/01/2012 11/01/2012 12/01/2012 01/01/2013 02/01/2013 03/01/2013 04/01/2013 05/01/2013 06/01/2013 07/01/2013 08/01/2013 09/01/2013 10/01/2013 11/01/2013 12/01/2013 01/01/2014 02/01/2014 03/01/2014 04/01/2014 05/01/2014 06/01/2014 07/01/2014 08/01/2014 09/01/2014 10/01/2014 11/01/2014 12/01/2014 01/01/2015 02/01/2015 03/01/2015

Please send me information on Medicare Advantage plans
in my area which my doctors participate in.

Doctor #1   Name Type of doctor Office zip code
Doctor #2   Name Type of doctor Office zip code
Doctor #3   Name Type of doctor Office zip code
Doctor #4   Name Type of doctor Office zip code
Doctor #5   Name Type of doctor Office zip code
Doctor #6   Name Type of doctor Office zip code
Doctor #7   Name Type of doctor Office zip code
Doctor #8   Name Type of doctor Office zip code
Doctor #9   Name Type of doctor Office zip code

I would also like to considering my particular current prescriptions when helping me choose a plan.
This is optional, of course. But we advise considering your prescription use when comparing plans. Some plans may provide
better coverage for your prescriptions than others, ans some may or may not cover your particular prescriptions.

List All Prescriptions Below:

Prescription #1   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #2   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #3   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #4   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #5   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #6   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #7   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #8   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #9   Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily
Prescription #10 Name    dosage     times daily once per week once every two weeks once every month once daily twice a day three times daily four times daily five times daily

Pharmacy(s) of choice:

Pharmacy #1  Name Zip code
Pharmacy #2  Name Zip code
Pharmacy #3  Name Zip code

Are you on Medicaid On Medicaid Yes No

Please contact me, I have questions.

Call me to schedule an appointment.