TIME FOR YOUR

ANNUAL MEDICARE REVIEW

Keeping your information up to date ensures we can recommend the

best options for you during Annual Enrollment.

Please Complete below per individual

Please complete per individual

First Name *

Last Name *

Phone *

Email *

Any health changes in the last 12 months? *

Current Medications - Please include the dosage and frequency of your medications. *

Current doctors: *

Please select the plan types you would like to discuss: *

Medicare Supplement

Medicare Advantage

Part D Prescription Coverage

We recommend the following umbrella coverage. Please indicate if you would like to learn about the following: *

Cancer Coverage

Heart Attack and Stroke Coverage

Skilled Nursing Home Care Coverage

None of the above

Do you have any other questions or comments for review?

The Medicare Annual Enrollment Period, October 15th thru December 7th, is a very busy time of year for an independent agent, just like an accountant is during tax season.

I understand that the team at Senior Savings Services will be in contact with me by email and/or phone during the Annual Enrollment Period.

I understand that I must also complete a Scope of Appointment form. The Centers for Medicare and Medicaid Services (CMS) requires a Scope of Appointment prior to a meeting with an agent and must be documented. This form gives the agent permission to discuss and quote specific plans during the enrollment period. The Scope of Appointment form will be shown to you after clicking submit below. All you need to do is sign and click submit then done!

I understand that I will not be automatically enrolled into any potential new plan and I will need to respond to my agent by phone at 515-218-8022 or email with my new plan selection and complete an application by 4:00pm December 7, 2025.

Scope of Appointment is shown after clicking Submit. All you need to do is sign and click submit when completed. Thanks!

Important disclosures about Medicare Plans: Medicare has neither endorsed nor reviewed this information. Not connected or affiliated with any United States Government or State agency. We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

https://seniorsavingsservices.com/privacy-policy/