Full Name

Phone *

Email *

Date of birth

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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

City *

State *

Country *

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

What prompted you to reach out?

Preferred Contact Method

Best Time To Reach

Medicare Number

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

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. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Consent to Contact

By checking this box and submitting this form, I consent to receive phone calls, text messages, and emails from Legacy Health Advisory Group regarding Medicare plan options, including calls made using an autodialer or prerecorded message. Message and data rates may apply. Consent is not a condition of purchasing any product or service. I can revoke consent at any time by replying STOP or contacting Legacy Health Advisory Group directly.