(303) 973-6636

(800) 295-5860

6638 W. Ottawa Ave, #120

Littleton, Colorado

info@hbsltc.com

www.medicarehbs.com

How to Get Started

To request your Medicare Planning Options Analysis, please complete the 3-step form on this page. Please be advised if you leave the page before finishing the final step, your progress will not be saved.
If you would prefer to download fillable forms click here.

2025 AEP

Annual Enrollment Period Personal Information Sheet

Please complete and submit the form below. If you would prefer to download a fillable form, click here.

View our Annual Client Newsletter by clicking here.

    Complete the Following:
    Agent Name:
    Client Name:
    DOB:
    Phone:
    Address:
    City:
    County:
    State:
    ZIP:
    Email:
    Tobacco Use Last 12 Months?
    Are you a current client?
    If not, how did you hear about us?
    Computer and Internet Access
    Please select your current coverage

    SECTION A: Fill Out This Section ONLY if you have a Medicare Supplement (Medigap) and Part D Drug Plan

    Medicare Supplement Company Name (on your Insurance Card)
    Type: (F/G/Other)
    Plan Name of Current Prescription Drug Coverage (on your Insurance Card)
    Are you considering changing to a Medicare Advantage Plan?

    SECTION B: Fill Out This Section ONLY if you have a Medicare Advantage Plan

    Medicare Advantage Plan Name (on your Insurance Card)
    Please select an option
    Please tell us why?
    Are you okay with changing doctors?

    SECTION C: Prescription Medications (REQUIRED to complete your drug analysis)

    Please select an option
    Current Pharmacy Name

    (VERY IMPORTANT)
    Medications List

    Please list your current medications.

    • Be sure to provide the Complete Drug Name from Bottle/Container.

    • DOSE/SIZE: Be sure to list BOTH dosage and container size for Inhalers, Drops, Lotions, Creams, Ointments and Gels.

    • Please DO NOT list “AS NEEDED“ – Complete Refill Frequency with one of the available options.

    • *Answer "Yes" if using GoodRx or any other discount drug plan to fill medication.

    Drug Name EXAMPLE: Metoprolol Succinate ER
    Dosage/Size EXAMPLE: 50mg
    Form Tab
    # per Refill EX: 90
    How Often Refilled Quarterly
    Generic OK?Yes
    Using GoodRx? Yes
    Drug Name EXAMPLE: Albuterol Sulfate HFA
    Dosage/Size EXAMPLE: 90mcg/8.5g
    Form Inhaler
    # per Refill EX: 1
    How Often Refilled Monthly
    Generic OK?Yes
    Using GoodRx? No
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?
    Drug Name
    Dosage/Size
    Form
    # per Refill
    How Often Refilled
    Generic OK?
    Using GoodRx?

    SECTION D: Fill out this section ONLY if you want to change Medicare Advantage plans OR move from your Medicare Supplement (Medigap) to Medicare Advantage

    Primary Care Dr. Name:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Eye Doctor:
    Phone:
    Dentist and Practice Name:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Specialist Name/Type:
    Phone:
    Disclaimer: Sharing this information with us is strictly voluntary. The information is used to create a more accurate plan analysis based on your specific needs as presented by Medicare’s Official Website.

    Scope of Sales Appointment Confirmation Form

    The Centers for Medicare and Medicaid Services requires agents to document the scope of a marketing appointment prior to any face-to-face sales meeting to ensure understanding of what will be discussed between the agent and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential and should be completed by each person with Medicare or his/her authorized representative.

    Please initial below beside the type of product(s) you want the agent to discuss.
    Product type descriptions can be found at the bottom of this page.

    Standalone Medicare Prescription Drug Plans (Part D)
    Medicare Advantage Plans (Part C) and Cost Plans
    Dental/Vision/Hearing Products
    Hospital Indemnity Products
    Medicare Supplement (Medigap) Products

    By signing this form, you agree to a meeting with a sales agent to discuss the types of products you initialed above.

    Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the Federal government. This individual may also be paid based on your enrollment in a plan.

    Signing this form does NOT obligate you to enroll in a plan, affect your current enrollment, or enroll you in a Medicare plan.

    Beneficiary or Authorized Representative Signature and Signature Date:
    Signature - Sign Below with Cursor Or Touch (Touch Screen Devices)
    Signature Date
    If you are the authorized representative, please sign above and print below:
    Representative's Name
    Your Relationship to the Beneficiary
    Copyright © 2024 HealthCare Benefit Services, Inc. All rights reserved.