Let's get ready for your Medicare review

Hi, I'm your agent.

Licensed Insurance Agent, FitPass LIFE

Tell me about your coverage, doctors, and medications. It takes about 5 minutes. At the end, you'll pick a time to meet with me one-on-one.

Your answers save automatically on this device, so you can stop and come back later.

First name

Last name

I'll send your meeting confirmation here.

Mobile phone

Someone is helping me fill this out

About you

Plans and prices depend on where you live, so your address matters here.

Date of birth

Month

Day

Year

Gender (optional)

Street address

Apartment or unit (optional)

ZIP code

City

State

County

How should we reach you?

Phone call Text message Email

Best time to reach you (optional)

Your Medicare today

Your red, white, and blue Medicare card shows your Part A and Part B start dates.

Part A start date

Month

Year

I don't have Part A yet

Part B start date

Month

Year

I don't have Part B yet

What coverage do you have now?

Do you get Medicaid or Extra Help with drug costs?

Yes, Medicaid Yes, Extra Help No I'm not sure

Your doctors

Add the doctors you see. I'll check which plans include them.

I don't have a regular doctor

Doctors you've added

Your medications

Add each prescription you take. Drug costs are often the biggest difference between plans.

I don't take any prescription medications

Search for a prescription

Type at least 3 letters of the brand or generic name.

Your prescriptions

Your pharmacy

Drug prices can change by pharmacy, so I'll price plans at the one you use.

Pharmacy you use most

Its location (optional)

A street or nearby intersection helps us find the right one.

Would you use mail-order delivery? (optional)

Yes No Open to it

How is your coverage working for you?

A few quick questions so our time together focuses on what matters to you.

Overall, how happy are you with your current coverage?

Very unhappyVery happy

This year, your out-of-pocket costs were

Lower than expected About right Higher than expected

Have you had trouble seeing a doctor or specialist?

Never Sometimes Often

Which extra benefits have you used? (choose any)

What matters most to you in a plan?

Pick up to 3.

Low monthly premium Low copays Keeping my doctors Low drug costs Dental, vision, and hearing Fitness benefits Coverage when I travel Predictable costs

If you could change one thing about your coverage, what would it be? (optional)

300 characters left

Check your answers

Use Edit to change anything. Then sign below so we can meet.

Which plan types would you like to talk about?

Medicare requires a record of what we'll discuss before we meet. Choosing a plan type doesn't commit you to anything. Choose at least one.

Medicare Advantage (Part C) and Cost plans Stand-alone Prescription Drug Plans (Part D) Medicare Supplement (Medigap) plans Dental, vision, and hearing products

Type your full name to sign

I agree that typing my name is my electronic signature for this Scope of Appointment.

How may your agent contact you about Medicare plans?

Choose at least one. You can opt out any time.

Phone calls Text messages (message and data rates may apply) Email

I've read the privacy notice.

Thanks. I have your answers.

Now pick a time for us to meet. Our review takes about 30 minutes, and you can choose phone, video, or in person.

How would you like to meet?

Phone Video In person

What happens next

I compare the plans in your area against your doctors, medications, and pharmacy.
When we meet, I walk you through the best fits, in plain language, and answer every question.
If a new plan makes sense, I help you enroll between October 15 and December 7. If your current plan is still the best fit, I'll tell you that too.

Talk soon,
Jared

Let's get ready for your Medicare review

About you

Your Medicare today

Your doctors

Doctors you've added

Your medications

Medication

Your prescriptions

Your pharmacy

How is your coverage working for you?

Check your answers

Thanks. I have your answers.

What happens next