Forms

GO TO SCOPE FORM

EVERYONE NEEDS TO SIGN A SCOPE FORM

Print
Check the Boxes
Sign and date
You are the beneficiary, if applicable, your Authorized Representative is a Power of Attorney

Email to:

anne@a-a-insurance.com or send regular mail.

GO TO RX LIST FORM

RX LIST FORM

Print
Complete the medications name, dose and how much you use in 30 days
No vitamins, over-the-counter or drugs administered by the doctor or paid by a grant

Email to:

anne@a-a-insurance.com or send regular mail.

GO TO DOCTOR LIST FORM

DOCTOR LIST FORM
For Medicare Advantage

Print
Full name of the Doctor and the address where you see them

Email to:

anne@a-a-insurance.com or send regular mail.

GO TO CMS L 564 FORM

CMS L 564 FORM

Complete the Form

If you are a Spouse, you are the applicant
If you are the Employee, you are both the applicant and the employee

Print the form to give it to your employer.

Your Employer returns the form to you.

GO TO CMS 40 B FORM

CMS 40 B FORM

Complete the form with the information obtained on the Employer Form CMS L 564.

Information on both forms must match.

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