Medicare Plan Review Patient Information

We have teamed with the McKamey Insurance Group again to help with our plan reviews this year!

Don't worry - some of the same faces you have seen in the past have joined the McKamey Insurance Group so you won't have any drop off in care - and you can be confident you will be dealing with the same people you have trusted for years! The difference is that we now can offer more detailed information and can help with ALL aspects of Medicare instead of just Part D!

The response and reviews from last year were wonderful!!

After you complete your patient information you will be taken to the scheduling page.

Thanks!

First Name *

Last Name *

Mobile Phone Number
(home number if no mobile number) *

Email Address *

Confirm Email Address *

Date of Birth
(format is MM/DD/YYYY - use slashes) * +

Are you a current patient of Marcrom's Pharmacy?
CURRENT PATIENT = having your regular meds filled here in the past 6 months. *

Yes

No

Zip code where you live: *

Please list your current medications: *

What is your current plan?

Is your plan an "Advantage" plan or traditional medicare with Part D coverage? *

Advantage Plan

Traditional and Part D (and possibly a MediGap/Medicare Supplement plan)

Not sure

Do you have a Medicare Supplement Plan? *

How much is your Medicare Supplement (or Medigap) plan?

If you recall, who is your current Medicare Supplement plan company?

Todays Date *

Will this be a meeting for one or two people? *

One

Two

If at all possible both members of the couple should attend the meeting. *

I understand

Do you give permission to Marcrom's Pharmacy to share your current medication list with the McKamey Insurance Group? *

Yes

Information for Second Person

First Name: *

Last Name: *

Date of Birth (Person 2)
(format is MM/DD/YYYY - use slashes) * +

What is your current plan (person 2)? *

Do both parties give permission to Marcrom's Pharmacy to share your current medication list with the McKamey Insurance Group? *

Yes

Do you or your spouse qualify for any additional governmental help? *

Do you or your spouse have Tricare or VA benefits? *

Yes

No

Please explain who has Tricare and/or VA benefits: *

Is there anything else we need to know about your medication or your current plan?

Would you like to receive your Flu Shot when you come for your Medicare Part D review? *

Yes

No

Have you received any paperwork from your CURRENT plan regarding 2024? *

Yes

No

Will you bring that paperwork with you to your appointment? *

Yes

No

Will you bring a list of all of your current medications? (Sometimes we know that patients are forced by their insurance to get other medications elsewhere.) *

Yes

By submitting this form I am agreeing to receive texts and/or emails from Marcrom's Pharmacy and the McKamey Insurance Group. *

I agree

By signing this form, you agree to allowing a sales agent to contact you to discuss your Medicare plans. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current or future enrollment, or enroll you in a Medicare plan.

Please use your mouse or your finger if you have a touchscreen to sign below: *

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Please use your mouse or your finger if you have a touchscreen to sign below (2nd person in the appointment for a married couple): *

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