Medicare Review Questionnaire

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, CLU, ChFC.*

Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1–800–MEDICARE 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!
Name as it appears on your Medicare Card*

First Name Last Name
Email*
example@example.com
Preferred Phone #*

Area Code Phone Number
Is this a mobile phone or land line?*

Mobile phone - and, I prefer a phone callMobile Phone - and, I prefer texting rather than a phone call!Land Line / VOIP / "home phone"
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birthdate:*
Medicare Claim # (found on your Medicare Card/ type "N/A" if you don't have yours yet)
Part A Effective Date (Type "N/A" if you don't have one yet)
Part B Effective Date (Type "N/A" if you don't have one yet)
Do you use Mail Order?*

I use mail order for ALL of my Rx drugsI use a combination of Brick & Mortar pharmacies + Mail OrderI only use brick & mortar to pick up my Rx drugs
Which Brick & Mortar pharmacy do you prefer? EVEN IF YOU USE MAIL ORDER, please indicate a pharmacy. FOR EXAMPLE: Let's say you needed antibiotics, where would you drive in town to get them? *Please note we cannot search for the lowest priced pharmacy. There are far too many variables and the system doesn't sort that way. Please indicate your preferred brick & mortar pharmacy (please list no more than 2)**
If you're already on a Part D Plan how do you pay for it? If you're not yet, how do you prefer to pay for it going forward?

Auto DeductionI get a monthly billComes out of Social SecurityI'm not sure!
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.
Please list Rx Drug 1 (if none, type "N/A")*
Please list Rx Drug 2
Please list Rx Drug 3
Please list Rx Drug 4
Please list Rx Drug 5
Please list Rx Drug 6
Please list Rx Drug 7
Please list Rx Drug 8
Please list Rx Drug 9
Please list Rx Drug 10
Please list Rx Drug 12
Please list Rx Drug 13
Please list Rx Drug 14
Please list Rx Drug 15
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?
Who is your Primary Care Physician + zip code where your doctor is located?
List any specialists you see. Please include what type of specialist, and the zip code your specialist is located. Example: Dr Kevin Smith, cardiologist, 12345
Which hospital do you prefer? + zip code (some have multiple locations)
Are you interested in Dental & Vision options?

YESNOI'm not sure
Are you currently Medicaid?

YESNOYES, and on a spend-down
IF YOU ANSWERED "YES, and on a spend-down", how much $ per month?
Are you on Low Income Subsidy for your prescriptions?

YESNOI'm not sure
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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Medicare Review Questionnaire

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

Note:

Thank you! We will be in touch within 3 business days with your next steps.