This is a sample form. Submissions here are not saved.

A request from

Jordan Avery

Licensed Medicare Agent · Avery Benefits Group

Sharing your medication list lets me find the plan that covers your prescriptions at the lowest cost.

Please confirm your details and list your current medications. Fields marked * are required. Your answers are saved on this device as you go.

Your information

This form is for Margaret Holloway. Your name and email were entered by Jordan Avery and can’t be changed here, so it’s fine if you share an inbox or use a different email day to day.

First name

M.I.

Last name

On file with your agent. It only needs to be the address your agent uses to reach you.

Phone

Home address

County

Preferred pharmacy

Pharmacy name

Pharmacy city

Pharmacy state

Primary physician

Doctor's name

Start typing a first or last name and pick from the list, or just type the name.

Medicare details

Medicare number

For your security we don't pre-fill this. The number on file ends in MK72. Enter all 11 characters from your red, white, and blue card.

Part A effective date

Part B effective date

MedicareHealth insurance

Name/Nombre

JOHN L SMITH

Medicare Number/Número de Medicare

1EG4-TE5-MK73

Entitled to / Con derecho a

HOSPITAL (PART A)

MEDICAL (PART B)

Coverage starts

03-01-2016

Your number and Part A/B dates are on the front of your card.

Current drug coverage

I am currently covered through

Which company holds your plan?

Current monthly premium

Your medications

Add every prescription you take regularly. Search by name, then choose the strength and how often you take it.

Medication 1

Medication name

Pick your medication from the list that appears.

Your information is private and only shared with Jordan Avery.

Jordan Avery

1Your information

2Preferred pharmacy

3Primary physician

4Medicare details

5Current drug coverage

6Your medications

Medication 1

Your information

Preferred pharmacy

Primary physician

Medicare details

Current drug coverage

Your medications