Client Information Form

Please have Medicare ID ready before completing form.

Please correct the errors described below.

If any required questions do not apply to you, please enter N/A. This is a secure encrypted HIPAA-compliant document.

Residential Address (if different from above)

Alternate Number


If you selected 'Keep my plan' above, the next section is highly recommended, but optional. However, please scroll to the bottom to sign and 'Submit' if you chose to skip this option.

If you are 'Changing plans' or 'Exploring options', please complete the next section for the most accurate plan comparison.

All information entered is secure, optional, and HIPAA compliant.


PRESCRIPTION LIST (Click 'Add another prescription' for additional entries)

Add another prescription

Primary Care Provider (PCP)

Add alternate PCP


Add another Specialist

Important Facilities

IMPORTANT: I authorize my broker/agent to utilize any protected health information (PHI) I have voluntarily provided for the purpose of advising me regarding my health plan/other product options. I agree to be contacted by phone/email/text unless I state otherwise. No information will be disclosed to any third party. Any electronic storage, transmission, or material copy will be kept secure and protected. Thank you!

Your information will be encrypted.