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2. Name*
3. DOB*
   DOB
5. Address*
7. Phone #*
8. Email
10. Marital Status
    -- Select One --SingleMarried
11. Veteran
    -- Select One --YesNo
13. Medicare # (from Red/White/Blue card – including letter)*
15. Effective Date Part A*
16. Effective Date Part B*
18. Pharmacy Used
20. Please Send Me Details About

    1. Medicare Advantage Plans
    2. Medicare Part D Plans (Cover ONLY Medications)
    3. Medicare Supplemental Plans
    4. EPIC Or Other Extra Help Programs
22. Other Considerations
24. I would particularly like information on plans with this insurance company. (write in name or preferred insurance company)
26. I do not want information regarding this insurance company. (write in name of any company to avoid)
28. Information should be sent to someone else as well who is helping me to sort out my options. (Name and address of contact)
30. I already have EPIC (EP #)
32. I have attached an updated drug list to this request so that I get the most accurate information.
34. My monthly income is
35. My spouse (if applicable) income is
37. Other/Comments (medical conditions, concern about coverage for specific items or procedures)
39. By submitting this request, I am authorizing Wayne County Department of Aging and Youth (A&Y) to research and send me information regarding my Medicare insurance benefits. I understand that A&Y does not have any ties to insurance companies and so can give me unbiased information about my options. I also understand that they will not recommend or select any particular insurance plan for me, the decision is mine alone. I consent to having my information entered in their database. I also consent to them sharing my information with EPIC, Department of Social Services, and Medicare if they need to get information to better inform me of my insurance options. I understand that I can call at any time to ask questions about the information being sent and can request to meet with an insurance counselor if I decide I am not comfortable sorting through the options on my own.
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40. Submit

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