YOUR 2027 MEDICARE REVIEW

IN PREPARATION FOR MEDICARE AEP 2027

The annual enrollment period for Medicare is October 15th through December 7th. Please consider completing this VOLUNTARY NEEDS ANALYSIS FORM, to help prepare for our annual conversation together.

Lisa Dailey Insurance

YOUR 2027 MEDICARE REVIEW

Optional Medicare Needs Analysis Form

About This Form

This optional Needs Analysis Form helps me prepare for your annual Medicare review and focus on the things that matter most to YOU ~ your doctors, prescriptions, healthcare needs, costs, and personal preferences.

You do NOT need to answer every question. Please complete the sections that apply to you and provide as much information as you'd like. Even a partially completed form can help me prepare for our conversation.

IMPORTANT FOR COUPLES - Please complete a separate Needs Analysis form for each person. It's important that I don't overlook important information for each of you, especially when your needs may be different.

THANK YOU!

Note: Your information is submitted securely through Hushmail. Completing this form is optional and does not enroll you in a Medicare plan or obligate you to make any changes to your coverage.

By submitting this form, you are giving Lisa Dailey Insurance permission to contact you regarding your Medicare coverage and the information provided on this form.

1. ABOUT YOU

First and Last Name:

Date of Birth:

County Where You Reside:

Phone Number:

Is it okay to text you at this phone number?

Yes

No

Email Address:

If you don't have an email address, type N/A

Are you currently a client of Lisa Dailey?

Yes No

If NO, what type of Medicare coverage do you currently have?

Medicare Advantage Plan Medicare Supplement (Medigap ) + Part D Original Medicare Only Employer or Retiree Coverage Other I'm not sure

Current insurance company

Current plan name

Has your home address changed since our last review?

Yes No

Zip Code - Please Confirm

IF YES, or NEW CLIENT: Your home address including city, state, and zip code

Preferred Method of Communication (Check all that apply):

Phone

Email

Text

US Mail

2. YOUR DOCTORS, SPECIALISTS, AND HOSPITALS

Please list all doctors, therapists, specialists, dentists, etc. that provide services to you.

PRIMARY CARE DOCTOR

Doctor's Full Name, Clinic or Medical Group, City

SPECIALIST #1

Doctor's Full Name, Clinic or Medical Group, City

SPECIALIST #2

Doctor's Full Name, Clinic or Medical Group, City

SPECIALIST #3

Doctor's Full Name, Clinic or Medical Group, City

SPECIALIST #4

Doctor's Full Name, Clinic or Medical Group, City

SPECIALIST #5

Doctor's Full Name, Clinic or Medical Group, City

Additional Doctors or Clinics

Is there a hospital or healthcare system you prefer to use?

Yes No No Preference

If Yes, which one?

Are there any doctors, specialists, hospitals or healthcare systems that are especially important to you and that you would prefer NOT to change?

3. YOUR PRESCRIPTIONS & PHARMACY

I do not currently take any prescription drugs.

Please check if applies.

If you'd like to upload a complete list of your prescriptions, you may upload it here.

Add file

Please upload a file

Your Preferred Pharmacy

Please provide name and address of pharmacy location.

Do you currently use a mail-order pharmacy?

Yes No

MEDICATION #1

Medication Name:

Strength/Dosage/Frequency:

Prescription Form Please check what applies:

Tablet

Capsule

Liquid

Inhaler

Cream/Ointment

Patch

Injection

Drops

Other

MEDICATION #2

Medication Name:

Strength/Dosage/Frequency:

Prescription Form Please check what applies:

Tablet

Capsule

Liquid

Inhaler

Cream/Ointment

Patch

Injection

Drops

Other

MEDICATION #3

Medication Name:

Strength/Dosage/Frequency:

Prescription Form Please check what applies:

Tablet

Capsule

Liquid

Inhaler

Cream/Ointment

Patch

Injection

Drops

Other

Additional prescriptions not listed above.

Please include all pertinent information about each medication listed.

4. CHRONIC CONDITIONS & SPECIAL NEEDS PLANS

Some Medicare Advantage Plans, called Chronic Condition Special Needs Plans (C-SNPs) are designed for people with certain qualifying chronic or disabling health conditions.

Do you have a chronic or disabling health condition that you believe may qualify you for a C-SNP plan?

Yes No I'm not sure

IF YES, or I'M NOT SURE:

Would you like me to explore whether a Chronic Condition Special Needs Plan (C-SNP) may be an option for you?

Yes No I'd like to learn more before deciding

If YES, please list the condition or conditions you would like me to consider when researching available C-SNP options:

Please note - Providing this information is optional. Eligibility for a C-SNP must be verified according to the plan's requirements.

5. WHAT MATTERS MOST TO YOU?

If Other, please explain

When it comes to premiums and healthcare costs, which statement sounds most like you?

Keeping my monthly premium as low as possible is most important. I'd rather have more predictable costs when I receive healthcare. Both are equally important to me. I'm willing to pay more each month for coverage or features that are important to me. I'm not sure - I'd like Lisa to help me compare.

What is MOST important to you about your Medicare coverage for the year ahead?

6. OTHER COVERAGE & FINANCIAL ASSISTANCE

Do you currently have, or have access to, any of the following? Check all that apply.

Employer or retiree health coverage

Medicaid benefits

VA healthcare benefits

TRICARE

Other health coverage

None of the above

I'm not sure

Do you currently receive Extra Help with your prescription drugs?

Yes No I'm not sure

Do you receive assistance paying your Medicare premiums or other Medicare costs?

Yes No I'm not sure

Do you currently pay an additional income-related amount (IRMAA) for Medicare Part B and/or Part D?

Yes No I'm not sure

7. WHAT COMPANIES WOULD YOU LIKE ME TO REVIEW?

A Note About the Carrier List:
The carriers and plan types listed below reflect those I am currently offering for new enrollment. If you do not see your current carrier, plan type, or county listed, it does not mean I am not appointed with that carrier or that I am no longer your agent. Some carriers are limiting or suppressing new enrollments for 2027. The counties shown are those where I currently do business and are not necessarily the carrier's complete service area. Ask about C-SNP and D-SNP plan offerings.

Please review all official notices from your insurance company regarding changes to your current plan for 2027. During AEP, we can review your current coverage and discuss the options available to you.

Is there another Medicare insurance company or plan you've seen or heard about that you'd specifically like me to investigate?

Yes No

If YES, Insurance Company or Plan Name:

8. CHANGES I SHOULD KNOW ABOUT

Have there been any important changes you want me to know about since our last review? Anything else you'd like me to know before our next conversation?

What can I do as your insurance advisor, to offer you the very best service for the year ahead?

9. SCHEDULING YOUR MEDICARE REVIEW

My regular Medicare appointment hours are:

Monday - Thursday 10:00 AM - 6:00 PM
Friday 10:00 AM - 3:00 PM
Saturday - Ask for my availability

Please give me up to THREE dates AND approximate times that would work well for you.

PLEASE NOTE: All appointments are filled up through 10/25/2026. Please request appointments after that date.

CHOICE #1 Date & Approximate time

CHOICE #2 Date & Approximate time

CHOICE #3 Date & Approximate time

How would you like to meet?

Telephone Virtual Teams Meeting In person - Available for Central Oregon clients only No preference

How would you like to receive your required Scope of Appointment form?

Electronic by Email Electronic by Text Paper Copy

Please find form and upload links here: https://www.lisadaileyinsurance.com/needs-analysis-form

10. WOULD YOU LIKE TO JOIN MY NEW EMAIL NEWSLETTER?

From time to time, I'll send helpful insurance information, updates, tips, and other news I think you may find useful.

Please choose one:

YES - Please add me to your newsletter email list. NO - Not at this time.

PLEASE NOTE: For my current clients, you are already on my client communication list so I can contact you about important matters related to your insurance coverage.

Your answer above applies only to my optional newsletter and will not affect those important client communications.

11. WOULD YOU LIKE TO SHARE YOUR EXPERIENCE?

If I've been helpful to you, I'd be grateful if you would consider leaving a Google review.

Your feedback helps others who may be looking for Medicare guidance know what it's like to work with me.

Leave a Google Review

Thank you! Your trust and kind words mean a great deal to me.

Is there anything else you'd like to tell me or any questions you'd like to make sure we discuss during our Medicare appointment?

Today's Date:

Thank you for taking the time to complete your Medicare Needs Analysis.

Remember, you don't need to answer every question. I'll use the information you've provided to help me prepare for our conversation, and we can fill in any missing information together.

If you're completing this as a couple, I encourage each one of you to complete the form individually.

Completing this form does not enroll you in a Medicare plan or obligate you to make any changes to your current coverage.

Please be sure to press the SUBMIT button before leaving this page.

Your information will be encrypted.

Lisa Dailey Insurance

Medicare Disclaimer: Medicare marketing, sales, and enrollment calls are recorded as required by CMS | I do not offer every plan available in your area. Currently, I represent 10 organizations which offer up to a total of 216 products, depending on your area. Please contact Medicare.gov or 1-800-Medicare to get information on all your options. Scope of Appointment forms are required prior to any sales meeting.

971-207-1059 Talk and Text
www.lisadaileyinsurance.com

Loading...