Full Name

Phone *

Email *

Date of birth

By checking this box, I consent to receive non-marketing text messages from Legacy Health Advisory Group about Medicare, Medicare Supplements, Medicare Advantage Plans, RX Plans, and other Insurance Products. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from Legacy Health Advisory Group at the phone number provided. Frequency may vary. Message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

Address

Street Address

Country *

State *

City *

Postal Code *

Who Is Completing This Form

Self

On behalf of a parent or family member

Representative Name

Representative Relationship To Applicant

Representative Phone

Representative Attestation

I confirm I have permission from the applicant to share this information on their behalf

Current Medicare Coverage Status

Every 6 months

Preferred Contact Method

Best Time To Reach

Medicare Number

We ask for this only so we can check your plan options accurately. You can leave it blank and give it to us later.

How Many Doctors

Doctor 1 Primary Care Physician Name

Doctor 2 Type

Doctor 2 Name

Doctor 3 Type

Doctor 3 Name

Doctor 4 Type

Doctor 4 Name

Doctor 5 Type

Doctor 5 Name

Doctor 6 Type

Doctor 6 Name

How Many Medications

Medication 1 Name

Medication 1 Dosage

Medication 1 Frequency

Medication 2 Name

Medication 2 Dosage

Medication 2 Frequency

Medication 3 Name

Medication 3 Dosage

Medication 3 Frequency

Medication 4 Name

Medication 4 Dosage

Medication 4 Frequency

Medication 5 Name

Medication 5 Dosage

Medication 5 Frequency

Medication 6 Name

Medication 6 Dosage

Medication 6 Frequency

Medication 7 Name

Medication 7 Dosage

Medication 7 Frequency

Medication 8 Name

Medication 8 Dosage

Medication 8 Frequency

Medication 9 Name

Medication 9 Dosage

Medication 9 Frequency

Medication 10 Name

Medication 10 Dosage

Medication 10 Frequency

Add any medication not listed above, one per line, with the name, dosage and how often you take it. Use this box too if you picked “Other” for a name, dosage or frequency above and need to tell us what it is.

Preferred Pharmacy

Preferred Pharmacy (Other, type name)

How often do you refill Medication 1?

How often do you refill Medication 2?

How often do you refill Medication 3?

How often do you refill Medication 4?

How often do you refill Medication 5?

How often do you refill Medication 6?

How often do you refill Medication 7?

How often do you refill Medication 8?

How often do you refill Medication 9?

How often do you refill Medication 10?

Consent to Contact

By submitting this form, I agree that Legacy Health Advisory Group may call, text or email me about my Medicare options

Disclosures: Legacy Health Advisory Group is an independent, licensed entity operating under Sobel Ventures Group, LLC. Legacy Health Advisory Group is a licensed insurance agency and is not connected with or endorsed by the U.S. government or the federal Medicare program. We do not offer every plan available in your area. Currently, we represent 3 organizations which offer 24 products in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.