Provider Lookup Questionnaire

Thank you for your interest in Medicare Advantage plans!

Medicare Advantage plans utilize a doctor/provider network. Please complete the HIPAA Compliant questionnaire below so that we can confirm if your providers are in-network.

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

Would you like to provide Doctor information for a SPOUSE/PARTNER (if applicable)?(Required)

Yes

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

Primary Care Doctor(Required)

Willing to change providers?(Required)

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)

Doctor 1(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 2(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 3(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 4(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 5(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 6(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 7(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 8(Required)

Specialty(Required)

Willing to change providers?(Required)

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

Primary Care Doctor sp(Required)

Willing to change providers?(Required)

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)

Doctor 1 sp(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 2 sp(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 3 sp(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 4 sp(Required)

Specialty(Required)

Willing to change provders?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 5 sp(Required)

Specialty(Required)

Willing to change providers?(Required)

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)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Doctor 8 sp(Required)

Specialty(Required)

Willing to change providers?(Required)

Address(Required)

City(Required)

State(Required)

Zip(Required)

Preferred Provider List

YOUR Doctor Info

SPOUSE/PARTNER'S Doctor Info

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