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Medicare Review Intake

Medicare Review

Medicare Review Intake

Please complete this short form before your appointment so your current coverage, doctors, prescriptions, and any protection concerns can be reviewed ahead of time.

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

Basic Information

First Name *

Last Name *

Date of Birth *

ZIP Code *

Phone Number *

Email Address *

Use the same email address you used to book your Medicare Review.

Current Coverage

Current Medicare plan / insurance company *

Doctors

Primary Care Doctor *

Specialists You Want to Keep

Prescriptions

Current prescriptions *

List the medication names only. Dosage and frequency are not required.

Pharmacy

Preferred Pharmacy *

Reason for Review

What made you decide to book a Medicare review? *

Providence changes Want to compare my options Doctor / network concern Prescription concern Benefits / costs Current plan isn't working well I just want to make sure I'm set up correctly Other

Quick Protection Screening

Have you had any major hospital stays or significant health changes within the last 2 years? *

Yes No

If yes, briefly explain.

Have you been diagnosed with diabetes? *

Yes No

If yes, please share any relevant details, including insulin or other diabetes medications.

Have you been diagnosed with a heart condition? *

Yes No

If yes, please briefly describe the condition and any related medications or treatment.

Do you currently have additional coverage outside of Medicare for: *

Hospital stays Cancer Heart attack / stroke Home care Dental None Not sure

Which would concern you most financially? *

Unexpected hospital stay Cancer / heart attack / stroke Needing help at home Dental expenses None of these are a major concern

Final Question

Is there anything specific you want to make sure we cover during your appointment?

Your information will be securely sent for your appointment review.

Thank You

Your Medicare Review intake has been received. I’ll review your information before our appointment.

Contacts

landonrichteam@gmail.com
(+1) 971-529-1085

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© 2026 Veyl Advisors. All rights reserved.

We do not offer every plan available in your area. Currently we represent 7 organizations which offer 42 products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.