Plan Recommendation | Worldwide Emergency Coverage

CONSULTATION FORM

Please fill out the form prior to your appointment. Forms are individual. If you have a spouse applying you will need to fill out a separate form just for them.

First Name *

Last Name *

Email *

Address Info

Address *

City *

State *

Postal code *

Do you have a separate mailing address?

Mailing Address (if different from primary address)

Please include full mailing address including city, state, and zip code.

Contact Info

Phone

Non-US Phone Number

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Demographics

Gender *

Date of Birth *

Medicare Info

Medicare Number (from red, white and blue card) *

On your red, white & blue Medicare card, does it show that you have Part A and Part B? *

Doctors & Medical Providers

Do you want to make sure any particular doctors are covered by your plan? What are their names?

Think of any primary care doctors, specialist doctors, prior surgeons, or hospitals in the US. We need to look up all your providers to make sure they are in-network with whatever plan we look up for you.

Prescriptions

Do you want your insurance to cover any medications? If so, what are (a) names, (b) daily quantities, and (c) dosages?

Keep in mind that coverage for prescriptions is only for U.S. pharmacies.

Other Coverage

What non-Medicare coverage do you have?

Do you have any Medicare plan(s) in addition to Part A and Part B?

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