2026 Medicare Annual Enrollment Client Review Form
- Devin Rubin
- Dawn Rubin
- Martin Picinic
- Shane Smith
- Brittney Anderson
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Please provide your Medicare ID
REQUIRED TO REVIEW YOUR MEDICARE ADVANTAGE PLAN:
Medication List
We need to know if you take generic or brand and the frequency and complete name of the medication as written on your medication bottle
We need to know if you take generic or brand and the frequency and complete name of the medication as written on your medication bottle
List of Doctors
(include name, address, and specialty)
By submitting this form, I consent to Golden Years Design Benefits to contact me by email, telephone, or text message at the email or telephone number I provided for advertising or telemarketing purposes using an automatic telephone dialing system or artificial prerecorded voice. I understand that my consent to receive these calls, text messages, or emails is not a condition of purchase of any goods or services. We are not affiliated with or endorsed by the U.S. Government or the Federal Medicare Program. We are insurance brokers. This is a solicitation of insurance. .
