We’re looking forward to meeting with you. Please watch the short instructional video below for 3 VERY IMPORTANT guidelines to remember as you fill this out.

 

Recap:

1. Please fill this out in one sitting, the form does not save halfway through.
2. Please submit 7-10 days before your meeting.
3. Please use separate email addresses for each spouse. Please do not share email addresses. If you do, they will override each other, and we will not get your information.

Thanks! We look forward to seeing you soon!


Information Request Form

  • Part 1 - Contact Information:

  • Part 2 - Personal Information:

  • Male or Female?
  • Part 3 - Medicare Insurance Information:

  • Medicare Part A & B
  • Part 4 - Current Insurance Information:

  • i.e. United Health Care - $533 per month
  • (ie 11/1/1998 to 04/30/2016) ** Please just be approximate. doesn't have to be exact.
  • Part 5 - Health Information:

  • Medications:

    PLEASE READ THOROUGHLY!! Please list the actual complete name on the bottle. If you take the brand, give us the brand name; if you take the generic, give us the generic name. Please do not give us both. It will affect the cost of your plans. You do not have to give us your over the counter medications, only prescriptions. • If you use an inhaler, please let us know the size, and how many aerosols you go through per month, on average. • If it is PRN, or on an As-needed basis, please let us know approx. how many pills you use per month. • If it is insulin, please specify if you use the vials or the kwikpens; and list how many pens/vials you use per month. • If it is a cream or eyedrops, please specify how many tubes or bottles you use on a monthly or annual basis.
  • Please list all of your medications in this format: Lisinopril / 10mg / 1 time per day; or Flovent HFA / 10mcg / approx. 15 aerosols per month
  • Doctors:

    PLEASE READ THOROUGHLY!! It is important to us that you are able to continue with your same doctors when you switch to medicare. Because of that, we are going to look up all your doctors in the provider networks of all the medicare plans in Kansas City before we meet so that we don't recommend a plan to you that your doctor doesn't take. In some instances we will call your doctor to ensure he accepts the plan. Please provide as much detail as you can so we find YOUR Doctors. For an example, there are dozens of Dr. Smiths, and dozens of Dr. Williams, so that will not help us find your doctor. So the more information the better!
  • Please list all your doctors in the following format: Physicians(s) Name / Address / Phone #
  • Please list all your doctors in the following format: Dentist(s) Name / Address / Phone # (type n/a if it does not apply)
  • Please list all your doctors in the following format: Eye Care Providers(s) Name / Address / Phone # (type n/a if it does not apply)
  • Hospitals & Pharmacies:

  • Please list any hospital preference(s) :
  • Please list any pharmacy preference(s):
  • That's it! I promise this was the hard part, from here on out, it's smooth sailing.

  • I authorize EnlightnU LLC to put together a plan recommendation based on this information.