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David Pre-Consultation Worksheet

David Baycroft’s Medicare Consultation Worksheet

To help me prepare for your Medicare consultation and ensure the most personalized guidance, could you please complete this Pre-Consultation Worksheet?

Your confidential information about prescriptions, doctors, and preferences will help narrow down the myriad of options, so we can focus on the plans most likely to match your needs and what is important to you.

I appreciate you taking the time to answer what you can. Please don’t hesitate to contact me if you have any questions.

Name(Required)
Location(Required)
MM slash DD slash YYYY
I currently have Medicare(Required)
I Currently Have (check all that apply):

Current Insurance Plan (If applicable):

Do you like using a provider network (like HMO or PPO)?
Do you mind needing a referral in order to see a specialist?
Do you travel or live outside your home area for extended periods (e.g., snowbird)?
I am willing to use a pharmacy network:
I prefer mail-order prescriptions:
Your Prescription Medications (add as many as needed using the plus sign + at the end of the row):
MEDICATION (example: Atorvastatin)
DOSAGE (example: 20mg)
TYPE (Be specific: tablet, capsule, other)
QUANTITY PER MONTH (how many do you take per month?)
 
Do You Currently See A Dentist?
Types of dental services you use or anticipate needing:
Additional Coverage I am interested in:
LICENSED STATES

Arizona, Oregon, Texas, Washington, and  California License #6000417

CONTACT INFORMATION

Office@What-Supp.net

(253) 884-7940

OFFICE HOURS

MON - FRI: 8:00 - 4:00 PST

WhatSupp Insurance Solutions, LLC does 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 your options. WhatSupp Insurance Solutions, LLC is not affiliated or endorsed by Medicare or any government agency. WhatSupp Insurance Solutions, LLC does not discriminate based on race, color, national origin, age, disability, or sex. Contacting WhatSupp Insurance Solutions, LLC will direct you to a licensed agent. No obligation to enroll.

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