2027 AEP Existing Client Intake Form

Annual Client Review

2027 AEP Existing Client Intake Form

Please complete this short form before your appointment so we can make sure your information is up to date and prepare for your review.

Before you submit: please answer each question so we can prepare for your appointment review.

Basic Information

Doctor Changes

Has your primary care doctor changed since our last review?
Have you added, changed, or stopped seeing any specialists since our last review?

Prescription Changes

Have any of your prescriptions changed since our last review?
Dosage and frequency are not required.

Pharmacy

Has your preferred pharmacy changed since our last review?

Health Changes

Since our last review, have you had any major health changes, procedures, hospital stays, or new diagnoses?

Quick Protection / Ancillary Review

Have you ever been diagnosed with any of the following?
Have you been hospitalized within the last 2 years?
Do you currently use tobacco or nicotine products?

Existing Additional Coverage

Do you currently have any additional coverage outside of your Medicare plan for any of the following?

Coverage Concerns

Which of these would concern you most financially if it happened?

Current Medicare Coverage

Final Question

Your information will be securely sent for your appointment review.