Medicare Part D

Annual Election Period

Open Enrollment is November 15th to December 31st, 2006

For A January 1st Effective Date

Apply now to make changes!!!

We offer 4 different companies!!!
Let's Talk About Medicare!

With the many Medicare changes it can be hard to keep up. Let me help you sort through your options so you can make decisions with confidence. Complete the confidential form below and I will contact you with options and information that could help save you a great deal on your healthcare and prescriptions.

Note the https in the address and the gold or red lock at the bottom right of this window indicating that this page is secured and your information will be kept in confidence and not shared.
General Information
 
Your Name:
 
Street Address:
 
City
 
State
 
ZIP:
 
Country:
 
Length of time at this address:
 
E-mail Address:
 
Date of Birth:
 
Phone:
 
Social Security #:
Medicare Information
 
Medicare Claim Number:
 
Sex:
 
Hospital Part A Effective Date:
 
Medical Part B Effective Date::
 
Will you have additional prescription drug coverage?
 If Yes, complete the inset below.

Some individuals may have other drug coverage, including private insurance, TRICARE, federal employee health benefits coverage, VA benefits, or state pharmaceutical programs.

Name of other coverage:

ID #:

Group #:

 
Language preference:
 
Are you a resident in a long term care facility, such as a nursing home?:

If Yes, complete the inset below.


Name of facility:

Address of facility:

Phone number of facility:

 
Current Carrier:
 
Monthly Premium:
 

How much money did you spend out of pocket last year on Rx?:
 
Did you hit the coverage gap?:

Prescription Information
If additional medications are taken, you may write those in the
ADDITIONAL COMMENTS section of this application.

Medication:
Strength:
Daily Usage:
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Comments
  

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We also offer Life Insurance, Final Expense Plans, Dental, Vision, Long-Term Care.
Would you like a FREE Financial Review?  Contact me directly for more information.

Jeff Spainhour
Kiely Hines & Associates
215 Breckenridge Lane
Louisville, KY 40257-0669
502-569-2758 / 502-897-1533 Fax