Medicare Health/Drug Plan Review Request

Please complete and submit your information and I will contact you to set up an appointment. Prior to the appointment, a required survey will be emailed or texted to you from RetireFlo. The survey gathers information regarding your current medications, doctors, providers, and pharmacy, as well as the Scope of Appointment Form giving me permission to discuss products.

All fields with “(required)” must be answered.

Check the Products(s) for Review:

Medicare Supplement Review

Medicare Advantage Review

Prescription Drug Plan Review

Name

First Name

Last Name

Phone Number

(###)

###

####

Address

Zip Code

How would you like the survey to be sent to you? If text, please make sure the phone number listed above has texting ability.

Text

Additional Comments