Please complete the entire form to help us identify the Medicare plan(s) that meet your individual needs. This information will be kept strictly confidential.
Please list your preferred physicians, including full name, office address and phone number. Please do not include dentists.
Please list all current prescription medications as listed on your medication bottles. List only medications prescribed by your doctor. Exclude over-the-counter items.
RX Name: Coumadin (G)
How often: 1 a day
Please list the generic name if you take generic medications. If you take injectables/inhalers, list the number of vials/inhalers you use per month.
I have willingly provided the health information on this page to MB Senior Solutions (MBSS), administrator of RetireMed™, to assist in my selection of an individual health plan. I am seeking their recommendation for a Medicare plan that will meet my needs.
This is a solicitation of insurance. By providing this information, I agree that an authorized representative or licensed insurance agent/producer may contact me by phone, e-mail, or mail to answer my questions or provide additional information about Medicare Advantage, Part D or Medicare Supplement Insurance plans.
I understand the information on this form is not to be used for any purpose other than to assist in my Medicare health plan selection, I am not bound to accept their recommendation, and this service is offered at no cost to me. This authorization expires 120 days after my signature date.
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