AEP Drug Plan Checks

Applicant Information

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Date of Birth*

Do you use Tobacco products?*

Yes
No

Contact phone number*

Contact Email

Who is your current Advisor?*

Karla Wilson
Nikki Bruns
None

Do you reside with a spouse or with another adult?

Yes
No

Spouse/Partner Information

Spouse Name

First Last

Spouse Date of Birth

Does spouse use Tobacco products?*

Yes
No

Current Health Insurance Information

Medicare Information

Please press "+" button to the right to add additional lines

Person Name	Medicare number (as shown on card)	Part A effective date	Part B effective date

This field is hidden when viewing the form

Medicare number-dnu

As shown on Medicare card

This field is hidden when viewing the form

Part A effective date-dnu

As shown on Medicare card

This field is hidden when viewing the form

Part B effective date-dnu

As shown on Medicare card

Medicare plan type*

Medicare Supplement plan name*

Medicare Advantage plan name*

Plan premium*

Drug Plan Information

Current drug plan name (on card)*

Current drug plan premium*

Medicare Advantage Information

Current physician's name

First Last

Please list all specialists you are currently seeing

Please press "+" button to the right to add additional specialists

Specialty	First name	Last name

Medications

To determine approximate costs of a prescription drug program, please list all prescription medications you take. In the case of solutions, creams, or ointments, use size of container and refill frequency.

Please list your preferred pharmacies

Pharmacy name	Address

Please press "+" button to the right to add additional pharmacies

Medication List

Please press "+" button to the right to add additional medications

Person Name	Exact name of medication	Strength (Ex. 25mg or .05%)	Frequency (Ex. 2 per day)

Confirm the Accuracy of Your Information*

I have reviewed all the information above and its accuracy to the best of my knowledge. I understand incorrect information provided may lead to increased processing time.

I have reviewed my information