Print and complete this form and return to the Office on Aging via mail, email, or in person. This form is for Medicare beneficiaries who get their benefits or wish to get their benefits through an Advantage Plan such as Humana Gold Plus, AARP Medicare Complete, etc.

1. Medicare Advantage Plan Worksheet
The following questionnaire provides the necessary information that SHIP
volunteers and staff need to prepare a comparison report. Once completed, you
will receive a personalized report regarding the top 3 most affordable plans.
Name: _______________________________ Date of Birth: ________________
Address: ___________________________________________________________
City: __________________________ State: ______ Zip: _________________
Phone: ________________________ County: _____________________________
SSN (if different from Medicare number): _________________________________
What is your Medicare Claim Number? ___________________________________
What is your effective date for Medicare Part A? ___________________________
What is your effective date for Medicare Part B? ___________________________
In which area do you need more coverage?
Chiropractic Dental Diabetes Programs/Supplies
Diagnostic Tests Durable Medical Equipment
Hearing Home Health
Kidney Disease/Conditions Long Term Care Outpatient Rehabilitation
Podiatry Preventive Services Prosthetic Devices
Skilled Nursing Facility Transportation Vision
Other ______________________________________________
Do you have a Medicare Advantage Plan? Yes No
If yes, please list the name of the plan and the plan provider.
_________________________________________________________
Does the individual have subsidy or other assistance programs in place?
Yes No
If yes, which one(s)? QI1 QMB SLMB LIS QDWI Other __________