Deb & Jerry Dornbusch - Sovereign Select Insurance

Name*

First Last

Phone

Email*

Birth Date

Address*

Street Address Address Line 2 City State ZIP Code

Preferred Communication Method

Current Health Plan Name*

Current Health Plan Premium

Prescription Drug Plan

Prescription Drug Plan Premium

Current Plan Type*

Preferred Pharmacies:*

Do You Use Mail Order Pharmacy?

If Yes, Which Pharmacy?

Primary Care Physician & Facility*

Preferred Networks (i.e., Aurora, Froedtert, Prohealth)*

Provider Information:

Please list your other doctors including their specialty and facility.

Prescription Information:

Please include the name of the medication as it appears on your prescription bottle or container.

Actively Taking Medication?

Financial Needs*

Have you recently qualified for additional financial assistance including Low-Income Subsidy or Medicaid?

If Yes, What Do You Qualify For:

Rate Your Current Plan

Additional Comments:

Do You Plan On Keeping Your Current Medicare Plan?*

Any Issues Receiving Services From Your Current Providers?

If Yes, Please Explain:

Any Issues Receiving Services From Your Pharmacy?

If Yes, Please Explain:

How Likely Are You To Recommend Sovereign Select To A Friend Or Loved One?

Please Note Any Additional Questions Regarding Your Health Coverage: