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Preferred Provider List
First Name (as on Medicare ID Card)
(Required)
Last Name
(Required)
Email Address
(Required)
Name of your Preferred Hospital
(Required)
Location-City, State
(Required)
Your Provider Information
Medicare Advantage plans use provider networks. Please list your doctors and other healthcare providers so we can check which plans include them.
Do you have a Primary Care Doctor
(Required)
Yes
No
Primary Care Doctor
(Required)
Are you willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
How Many Additional Doctors Do You Currently See?
(Required)
0
1
2
3
4
5
6
7
8
Doctor 1
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 2
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 3
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 4
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 5
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 6
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 7
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 8
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Would you like to provide Doctor information for a SPOUSE/PARTNER (if applicable)?
(Required)
Yes
No
SPOUSE/PARTNER'S Doctor Info
Medicare Advantage Plans are network based plans. We will need a list of all of your doctors to find the most appropriate solutions.
Does your spouse/partner have a Primary Care Doctor
(Required)
Yes-Different than mine
Yes-Same as mine
No
Primary Care Doctor sp
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
SPOUSE/PARTNER-How Many Additional Doctors Do You Currently See?
(Required)
0
1
2
3
4
5
6
7
8
Doctor 1 sp
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 2 sp
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 3 sp
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 4 sp
(Required)
Specialty
(Required)
Willing to change provders?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 5 sp
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 6 sp
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 7 sp
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Doctor 8 sp
(Required)
Specialty
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Δ
