Doctor Input Form

  • 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.
  • Attestation

    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.
  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.