Appointment Worksheet – Maine Medicare Options

Thank you for scheduling your appointment. I’m looking forward to meeting with you.

To help us prepare, please take a few moments to complete this form. After you submit it, you’ll be guided to a second form that will require your signature before our meeting.

Full Name *First and Last Name

Phone *

Email Address

Physical Address

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

My Mailing Address is the same as my Physical Address

Mailing Address

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Are you a current client?YesNo

Great! Who referred you?First/Last Name and Organization if applicable

CheckboxI am turning 65 and would like guidanceMy medical situation has changedMy prescriptions have changedI have moved or am moving to a new county/stateI am unhappy with my current insurance companyI am unclear about changes to my planOther

Do you currently have Medicare?

Medicare ID (Optional)

Medicare ID Number0 / 13

Part A Effective Date

Part B Effective Date

Date of Birth

Providers

Primary Care PhysicianDr. A. Cureall – Fixer Upper Clinic, Shirley Mills 04485

DentistPhil Toothaker – Smiles-a-lot Assoc, Bangor

Optometriste.g. Dr. I. C. Nicely – Looking Good Eyecare, Gorham

Preferred Pharmacye.g. Rexall, Historyville

Specialists

I do not have any specialists

Specialists

Specialiste.g. Cariologist: Dr. Hart – Beatswell Health, Portland 04101

Prescriptions

I do not have any prescriptions

PrescriptionsYou only need to enter Pharmacy filled prescriptions. Over the counter prescriptions or medications don’t need to be entered.

Prescription Drug Namee.g. Relaxitol0 / 50

Dosagee.g. 500mg

Type

Quantity