Our office offers a varity of Medicare Supplement Plans and carriers.
   Complete the following form.

   Part A Hospital Insurance Medicare Effective Date:   
   Part B Medical Insurance Medicare Effective Date :

   Name (exactly as it appears on medicare Card)             Sex       Social Security Number
              
   Permanent Residence Address, Apt. No., Suite No.
  
   City                                 County              State / Zip
           
   Billing Address (if different)
  
   City                                 County                State / Zip
            
   Home Phone Number            Email Address                                        Date of Birth
           
   Current Coverage                Company Name                                      Plan
          
   Any health Conditions?
    
   Tabacco Usage?
   

  Cigrettes  Pipe  Smokeless  None

   
     Please read the following information on the upcoming Medicare
                                   Plan Part D.

   Learning The ABC's and D of Medicare

   What is Medicare Part D?

   Originally Medicare was comprised of just two parts: Part A, which is hospital insurance,
   and Part B, which is medical insurance. Medicare+Choice, currently called Medicare
   Advantage, was then added. The plan is frequently called Part C, however Medicare does
   not refer to it this way. In December 2003, Congress and the President enacted new
   legislation that will bring a new prescription drug benefit, Part D, to all Medicare
   beneficiaries starting in January of 2006. Understanding the legislation, and how we can
   assist our members, is our focus here.

   Medicare will contract with private companies to offer the Part D benefit. This benefit is
   known as a Presciption Drug Plan or PDP. People will have an opportunity to purchase
   Part D through one of these companies. If you are eligible for, or enrolled in Medicare, 
   you will receive information later this year about the Part D drug benefit. It is important
   to understand that seniors who are happy with their current coverage will have the choice
   to remain on their current plan, just as it is today.

   You may enroll in Part D through a Medicare Advantage Plan with prescription drug coverage,
   if one is offered in your area. Health care companies who offer your Medicare Advantage
   plans do so under a contract with Medicare to administer your Medicare benefits. These
   plans can be either a Medicare HMO (health maintenance organization) or a PPO (preferred
   provider organization) and will include the Part D prescription drug benefit.

   -Some prescription drug plans may have additional options to help low income
    members pay the out-of-pocket costs.

   -You will have the choice of ordering covered drugs through the mail or buying
     them directly from a network pharmacy.

    How does the new Drug Benefit work?
   Which Medicare Part D, for the first time ever, all people with Medicare wil be able to enroll
   in plans that cover prescription drugs. Plans may vary, but in general they will work like this:
   *You can choose a prescription drug plan and will pay a premium of about $35 a month.
   *You will pay the first $250 (called a deductiable) of your prescription drug costs.
   *Medicare then will pay 75% of costs between $250 and 2,250 for your drug spending.
     You will pay only 25% of these costs.
   *You will pay 100% of the drug costs above $2,250 until you reach $3,600 in out-of-pocket
     spending.
   *Medicare will pay 95% of these costs after you have spent $3,600.