Medicare Enrollment Checklist

Contact Trout Insurance for a complete review of Your Medicare Options. Agents are standing by.
Call 828.279.4681 today.

• Are you eligible for enrollment in 2023/2024? We can review guidelines for enrollment with you. Click Here.

• The Annual Enrollment Period (AEP) begins October 15, 2023 for members already enrolled in Medicare. Please contact us for exceptions.

Turning 65 - New to Medicare

• You may enroll in a Medicare plan three months before the month you turn 65, the month of your birthday, and 3 months after.

• All plans including Medicare Supplements are guarantee issue during this enrollment period (IEP).

We represent Medicare Advantage HMO, PPO and PFFs organizations with a Medicare contract. Enrollment in any plan depends on contract renewal. You must continue to pay your Medicare Part B premium.

Complete this form so we may get started to review your Medicare medical and Rx Prescription plan options for 2024.

2023/2024 Medicare Enrollment Form for Over 65

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Date of Birth *

Address *

City *

State *

My Current Agent Is: *

Zip *

County *

Medicare Part B eligibility date (on your Medicare Card) *

My Current Plan *

My Current Insurance Company *

Primary Care Doctor *

Specialist 1 *

Specialist 2 *

Have you been diagnosed with Heart Disease or Diabetes? *

Yes No

Your Preferred Local Pharmacy *

Prescriptions Taken Regularly:

Rx 1 Name *

Rx 1 Dosage *

Rx 1 How Often *

Rx 2 Name *

Rx 2 Dosage *

Rx 2 How Often *

Rx 3 Name *

Rx 3 Dosage *

Rx 3 How Often *

Rx 4 Name *

Rx 4 Dosage *

Rx 4 How Often *

Rx 5 Name *

Rx 5 Dosage *

Rx 5 How Often *

Rx 6 Name *

Rx 6 Dosage *

Rx 6 How Often *

Questions/ Comments/ Notes *

If you were referred to Trout Insurance, whom should we thank? *

Submit

Enroll for 2023/2024

2023/2024 Medicare Enrollment Form for Over 65

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