Finwell.Health

Help us prepare for your conversation

This optional preparation form helps your agent understand your needs. Skip optional questions you cannot answer. There is no cost or obligation.

A little preparation, a more useful conversation

Review Medicare Basics with Finwell when you can, or let us walk through it together. You are welcome to reach out either way.

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Help us prepare for you (optional) Before reaching out today, have you reviewed Medicare Basics with Finwell?

Any answer is welcome. This does not affect your ability to request a consultation.

What would you most like us to explain? How would you prefer to learn?

Not yet or unsure? We can explain the basics together. You can continue now.

Contact Information

First Name *

Last Name *

Date of Birth (optional)

Phone Number *

Email Address

Preferred Contact Method

Preferred Language

Your Address

Street Address *

City *

State *

ZIP Code *

Medicare Information

Medicare Number (optional)

Your Medicare number helps us verify your eligibility. It will be stored securely.

Medicare Effective Date I'm not sure of my effective date

Current Coverage Type

What are you interested in? (select all that apply)

Medicare Advantage Medigap / Medicare Supplement Prescription Drug Plans (Part D) Dental, Vision & Hearing Help Deciding — I'm Not Sure Yet

I'm an existing Medicare beneficiary looking to review my current coverage

Current Plan Name

Current Carrier

Current Monthly Premium

How often do you see your primary care doctor?

How often do you see specialists?

Special Situations

Tell us what you know. Your agent can help confirm the details.

Do you have Medicaid? Do you have VA coverage? Do you have TRICARE? Do you have CHAMPVA? Do you have a disability you would like your agent to consider?

Additional Details

This helps us identify programs like D-SNP plans or extra help benefits you may qualify for.

Your Preferences

Preferred Doctors or Providers

This helps us find plans that include your preferred providers.

Current Medications

This helps us check drug coverage and estimate costs.

Additional Notes

Consent & Submit

Scope of Appointment

The Centers for Medicare & Medicaid Services (CMS) requires agents to document the scope of an appointment before any individual sales meeting. By submitting this form, you are agreeing that a licensed insurance agent may contact you to discuss the Medicare products you have expressed interest in above. This agreement does not obligate you to enroll in any plan, affect your current enrollment, or require you to speak to the agent.

I agree to the Scope of Appointment and consent to be contacted by a licensed agent regarding the Medicare products indicated above. *

Review your answers

Use Back or a step number above to make changes. Blank optional answers mean not provided.

Privacy Acknowledgment

I acknowledge that the information I provide will be used to assist me with Medicare plan selection and enrollment. My information will be kept confidential and will not be sold or shared with unaffiliated third parties. *

A licensed agent will contact you within 1 business day.