Client Update

CLIENT UPDATE CENTER

Keep your information up to date.

Update your doctors, medications, pharmacy, health changes, and coverage information so your licensed agent has accurate information for your next review.

Important: This form does not enroll you in a Medicare plan or change your current coverage.

1. About You

Confirm your current contact information.

First name *

Last name *

Date of birth *

Phone *

Preferred contact

Home address

City

State

ZIP

2. Doctors & Specialists

Add your primary care doctor and specialists.

3. Medications

List your current prescriptions and regular medications.

4. Pharmacy

Pharmacy name

Pharmacy phone

Pharmacy address

Mail order?

Pharmacy changed?

5. New or Changed Health Conditions

Any new diagnosis?

Conditions / health changes

Upcoming surgeries, procedures, or specialist care

6. Coverage Changes

Medicaid status changed?

Extra Help / LIS changed?

Have you moved?

New employer / retiree coverage?

Anything else your agent should know?

7. Permission to Review

I certify that the information I provided is accurate to the best of my knowledge. I authorize Informed Choice Insurance to contact me about my requested policy review and service needs. I understand this form is not an enrollment application and does not change my current Medicare coverage.

Typed signature *

Date *

Thank you. Your information was submitted to Informed Choice Insurance.

We could not submit your update. Please try again or contact Informed Choice Insurance.

PERSONAL INSURANCE

FINANCE

Need Help Choosing?

FOLLOW US ON