Health Coverage Review v3

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CLIENT INFORMATION

First Name

Last Name

Phone Number

Street Address

City

Zip Code

Date of Birth

NOT YET ON MEDICARE?

If you're not yet on Medicare, you can browse ACA Marketplace plans yourself — go back to our homepage and look for the "ACA Marketplace" section. Prefer to talk it through first? We're happy to help — call 352-428-0417.

VA / MILITARY CARE

Do you receive military or VA benefits?

I receive all of my care through the VA I receive some care through the VA I do not use the VA TRICARE / TRICARE for Life CHAMPVA

WHAT MEDICARE PLAN ARE YOU ON NOW?

MEDICARE STATUS

I have Medicare Part A (Hospital Insurance) I have Medicare Part B (Medical Insurance) I have Medicare Part A and Part B I will be turning 65 soon — I am not yet on Medicare

MEDICAID & LOW INCOME BENEFITS

I have Medicaid coverage I receive Extra Help / Low Income Subsidy (LIS) for my prescriptions I receive SSI (Supplemental Security Income) I am not sure of my current benefits

CURRENT INSURANCE

I currently have a Medicare Supplement (Medigap) plan I currently have a Part D Drug Plan (PDP) I currently have Dental / Vision / Hearing coverage I have Employer / Retiree coverage I currently have no additional insurance

My Doctors

No doctors added yet — use the search or specialty buttons below.

Browse by Specialty — tap to see all doctors of that type

My Medications

No medications added yet — search or use category buttons below.

Browse by Category — tap to see common medications

EXTRA COVERAGE

Are you interested in any of these supplemental plans?

Dental / Vision / Hearing Cancer coverage Hospital Indemnity Critical Illness Accident coverage Disability Not Interested

NOTES

Any questions, or anything you'd like to add?

MY PHARMACY

No pharmacy added yet — use the search or filters below.

Show by Type

MY DENTIST

No dentist added yet — use the search or filters below.

Show by Specialty

HOSPITAL PREFERENCE

In the event of an emergency, which hospital would you go to? This helps Anthony's Healthcare verify your hospital is covered in network under your plan.

In an emergency, which hospital would you go to?

HOW DID YOU HEAR ABOUT US?

This helps Anthony's Healthcare better serve our community.

How did you hear about Anthony's Healthcare?

Complete This Form for a Callback

By submitting this form you are requesting a callback from Anthony's Healthcare to discuss your Medicare coverage options.

We review your doctors and medications
We verify provider networks and coverage
We prepare before speaking with you
We discuss your next steps together

No obligation to enroll. I am here to help.

Scope of Appointment — Required by CMS

Almost there! Please take a moment to check each box below so Anthony's Healthcare has your permission to discuss all plan options with you. Each box needs to be checked by you before we can submit.

Federal law (CMS regulations) requires that before a licensed Medicare insurance agent may discuss Medicare Advantage or Medicare Part D Prescription Drug Plans, the beneficiary must provide a Scope of Appointment (SOA). By checking the boxes below you are authorizing Anthony's Healthcare to contact you and discuss only the plan types selected.

Please check ALL boxes below to give Anthony's Healthcare permission to assist you with all Medicare coverage options (all required):

Medicare Advantage Plans (MAPD) — Plans that include medical and prescription drug coverage Medicare Prescription Drug Plans (PDP / Part D) — Stand-alone drug coverage Medicare Supplement (Medigap) — Plans that help pay costs Original Medicare does not cover Dental / Vision / Hearing Plans Life Insurance / Hospital Indemnity / Supplemental Plans

Beneficiary Acknowledgment: By checking the boxes above and signing below, I confirm that I am a Medicare beneficiary or authorized representative, I am requesting this contact, and I understand this is not an application for coverage. This Scope of Appointment is valid for 12 months from the date of submission. Agent: Anthony's Healthcare | License: Florida | NPN on file.

Beneficiary Signature (Required — one must be completed)

How to sign: Hold down your left mouse button and write your name in the box below. On a phone or tablet, use your finger.

Schedule Your Callback

Let me know when you'd like to hear from me.

Preferred Date Preferred Time

Alternate Date Alternate Time

Please note: If you have not completed the Scope of Appointment above, I am not able to call you back to discuss any plans. Please complete and sign the Scope of Appointment, and I will be happy to call you back.

Call Recording Consent

I consent to my callback call being recorded for quality assurance and compliance purposes. (Optional — you may decline without affecting your coverage review)

SAVE PROGRESS

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Health Coverage Review — Summary

Important Disclaimer

Anthony's Healthcare provides Medicare education and guidance only. We are not affiliated with or endorsed by the U.S. government, the federal Medicare program, or any state Medicaid agency.

Medicare consists of multiple parts (Part A, Part B, Part C, and Part D), each with its own rules, costs, and coverage limitations. Medicare Advantage (Part C), Prescription Drug Plans (Part D), Medicare Supplement (Medigap) policies, and Special Needs Plans (D-SNP, C-SNP) are offered by private insurance companies that are approved and regulated by Medicare.

Coverage, premiums, deductibles, copayments, coinsurance, provider networks, formularies, service areas, and extra benefits may vary by plan, carrier, county, and contract year and are subject to change. Extra benefits such as dental, vision, hearing, fitness programs, transportation, over-the-counter allowances, food or grocery benefits, meals, and in-home services are not guaranteed and may have limitations or eligibility requirements.

Information provided is for educational purposes only and does not guarantee eligibility, coverage, or enrollment.

We do not offer every plan available in your area. Any information we provide is limited to the plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

Submitting this form does not enroll you in a Medicare plan, and there is no obligation to make changes to your current coverage.

Your information is kept private and used only to contact you about Medicare options. We do not sell your data.