YesNo
YesNo
Medications
Please list all of your current prescription medications as they are written on your medication bottles (list generic name if used).

List only medications prescribed by your doctor and do not include over-the-counter items.
RX Prescription Name as on medication bottle (list generic if used)
Example: Rx Name – Lisinopril
Dosage
Example: Dosage - 20 mg
How Often
Example: 2x Day
Type – Tablet, Capsule, Cream, Drops
Providers
We only need providers if you are on a Medicare Advantage Plan OR ARE INTEREST IN LOOKING AT ADVANTAGE PLANS FOR 2023
Specialists, Durable Medical Equipment Providers, Dentist, Eye Doctor
Authorization
I have voluntarily provided the health information on this sheet to BIFS, LLC, dba Baker Insurance and Financial Services to aid in the choice of an individual health plan. I am pursing their advice for a Medicare plan that will best service my needs. I agree to receive my personal, no cost, no obligation recommendation, and I further authorize a licensed sales agent to contact me by phone, text, email, or mail, if needed. This information, provided to Baker Insurance, is not to be used for any purpose other than for my Medicare health plan selection. I understand I am not bound to accept their recommendation. By signing below, I am authorizing a licensed agent from Baker Insurance to contact me regarding my healthcare needs.