Medicare Appointment Information Form

Please fill out one per person

Thank you for allowing us to quote your Medicare Health Insurance. Please fill out the form below. Once completed simply scroll to the bottom and hit submit. Reach out with any questions... Joe 760-800-8200.

First name

Last name

Phone

Address

Short answer

Do you have your red, white and blue Medicare card.

Yes

Current Plan Information

Short answer

Long answer

Do you have any chronic conditions such as Diabetes, Cancer, or Renal Disease

Yes

Does the state help you pay for any part of your health coverage

Yes

What is the most important factor when making your health insurance decision:

Benefits such as Chiropractic, Acupuncture and Over The Counter

Keeping your Doctor's and Hospital

Price

If there someone who helps you make decisions about your healthcare or has POA. Please ask them to be present for our meeting

Is there any other additional information I should know