• Medicare Review Questionnaire

    This information will help us give you the best cost comparison for your needs for next year. Remember Open Enrollment for Medicare Parts C & D is October 15th-December 7th. You are not obligated to fill this out. By submitting this questionnaire, you are requesting a review of your current Medicare Part C (Advantage) or Part D (Prescription Drug Plan) plan.
  • *You are not required to provide any private, protected health information (PHI). The below requested information is for use by Mark E. Werner, MSFS, CFP®, RICP®, ChFC®, CLU®, ChSNC® only to help you make an informed plan decision and will not be shared with any third party. You will be providing the PHI voluntarily and without coercion from Mark E. Werner, MSFS, CFP®, RICP®, ChFC®, CLU®, ChSNC®*

    Disclaimer: We do not offer every plan available in your area. Currently we represent 6 organizations which offer 52 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

  • Grab a cup of coffee or tea, turn on some good music, take a deep breath... and let's begin!

    We know this can feel tedious. We are appreciative of your giving us the information Mark needs to help you make the best decision for you!
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  • Next, we need a list of your Rx drugs. 

    We need to know: 

    • THE NAME OF THE DRUG 
    • WHETHER IT IS BRAND NAME OR GENERIC (if you don't know, please call your pharmacy. WE won't know that answer, and it can mean the difference of thousands of dollars!) 
    • THE DOSAGE
    • HOW MANY TIMES PER DAY YOU TAKE THIS Rx DRUG (time of day does not matter, we just need to know quantity)  
    • The MORE you give us that the bottle says, the more we can be sure we match your exact dosage and needs
    • You won't necessarily fill out all of these, once you've entered in every Rx drug you are currently having filled, scroll to the bottom and hit SUBMIT 
    • If you are currently prescribed more than 15 Rx drugs, you may include more than 1 in each box. 
  • EXAMPLE: 

    Rx Drug Name, generic, .5mg, 1 tablet per day 

    Rx Drug Name, brand, 50mcg, 3 capsules per day 

    Rd Drug Name, generic, 10mg, the directions are 3x per day, but I only take as needed and take about 5 tablets a month. 

     

  • Note:

    If you don't take any prescriptions type "N/A" in the first box then scroll to the end and click/tap submit. You may also type more than one Rx in a box if necessary.
  • OK, great! Thank you for giving us that information. This next section is *only* for Medicare Advantage Plan policy holders (Part C) -- If you have a Medicare Prescription Drug Plan (Part D) then you are finished and may skip this section and scroll to the very end to click/tap the blue submit button. If you have an Advantage Plan (Part C), perhaps a quick stretch break before continuing? Don't forget to look out the window to give your eyes a break, too!

  • Hooray! You're done! Don't forget to click/tap the blue Submit button below! Once you click/tap submit, you will see a screen with a green check mark that says "Thank you, Your submission has been received." You will also get an email confirmation from Jotform at the email address you provided above (we will also get the same email alerting us you've completed the questionnaire).

    PLEASE NOTE: you do not need to create an account with Jotform!
  • Thank you! We will be in touch within 3 business days with your next steps.

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