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Preferred Provider List
First Name (as on Medicare ID Card)
(Required)
Last Name
(Required)
Email Address
(Required)
Would you like to provide YOUR Doctor information?
(Required)
Yes
No
Would you like to provide Doctor information for a SPOUSE/PARTNER (if applicable)?
(Required)
Yes
No
1st Choice-Hospital Name
(Required)
Location-City, State
(Required)
2nd Choice-Hospital Name
Location-City, State
YOUR 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.
Do you have a Primary Care Doctor
(Required)
Yes
No
Primary Care Doctor
(Required)
Willing to change providers?
(Required)
No
Yes
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
YOUR- Number of Additional Doctors currently see (if over 8, please contact HTA to schedule a phone appointment)
(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)
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- Number of Additional Doctors currently see (if over 8, please contact HTA to schedule a phone appointment)
(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
