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First name & Last Name & Gender
Full Address with Zip Code
Email & Phone Number
Birthdate, Best Time/Days to contact
Current Coverage, Local Hospital
Medicare ID Number (Optional),
Medicare Part A Effective Date (Optional), Medicare Part B Effective Date (Optional)
Premium, Deductable, Annual Income
Please List Doctors/Specialist
(please include RX name, dosage, conditions, and preferred pharmacy)
(MediGap,
Advantage,
PPO,
HMO,
I Don't Know, or
Other)