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Pre-Appointment Questionnaire

If we have an appointment coming up, filling this out beforehand lets us spend our time together on your options instead of gathering information. It takes about 5-10 minutes on your phone or computer.

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You’ll be asked about your current Medicare coverage, the doctors you see, and the prescriptions you take. If you’re not sure about an answer, skip it — we’ll go over it together.

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About You
Birthday
Month
Day
Year
Your Current Coverage
What type of Medicare coverage do you have now
Do you have a separate prescription drug plan?
Yes
No
Not sure
Do you get Extra Help paying for perscriptions?
Yes
No
Not sure
Do you have both Medicare and Medicaid? (AHCCCS)
Yes
No
Not sure
Your Doctors

List the doctors you see regularly so we can check whether they're in network. Leave any rows blank if you dont need them.

Need to keep?
Need to keep?
Need to keep?
Your Prescriptions

List the medications you take regularly so we can check coverage and pricing. Leave any rows blank if you don't need them.

How Often?
How Often?
How Often?
How Often?
How Often?
How Often?
How Often?
How Often?
Would you use mail order if it saved you money?
Yes
No
Maybe
What Matters Most to You
Which benefits are important to you? Check all that apply.
Your Appointment
How would you like to meet?

Your information is confidential and will only be used to prepare for your appointment.


This form does not enroll you in any plan.

We do not offer every plan available in your area. Currently we represent 6 organizations which offer 30 products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

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928 377-8966 TTY:711

Mathenyinsurancegroup.com

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Matheny Insurance Group is an independent insurance agency and is not affiliated with, endorsed by, or connected to the U.S. government, the Centers for Medicare & Medicaid Services (CMS), or the federal Medicare program.

Enroll With Us.

Click here to enroll with us

The above link can be used to view all Medicare plans that 

we are currently contracted with. You will also be able to view plan details, evidence of coverage, and access the RX search tool.

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