Seniormark - Medication Input Form & Prescription Information

Doctors and Hospitals
Please list all Doctors and Hospitals that you see on a regular basis. Please also list any doctors that you want to make sure are in-network for your plan.
This list of Doctors is for*
Email
Doctors
Doctor's Name Location Specialty

(Click ⊕ at end of row to enter additional doctors)
Hospitals
Hospital Name Location

(Click ⊕ at end of row to enter additional hospitals)
Additional Information
Consent
I have willingly provided the health information on this page to Seniormark, LLC, to assist in my selection of an individual health plan. I am seeking their recommendation for a Medicare plan that will meet my needs. This is a solicitation of insurance. By providing this information, I agree that an authorized representative or licensed insurance agent/producer may contact me by phone, e-mail, or mail to answer my questions or provide additional information about Medicare Supplement Insurance, Medicare Advantage, or Part D plans. I understand the information on this form is not to be used for any purpose other than to assist in my Medicare health plan selection, I am not bound to accept their recommendation, and this service is offered at no cost to me. This authorization expires 120 days after my signature date.
Comments
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Doctor's Name	Location	Specialty

Hospital Name	Location

Doctors and Hospitals