AEP Request Form

AEP Request Form

Please complete this form so we can research the proper 2023 plans for you.

Although we have most of your information regarding your prescriptions and doctors, Medicare is requiring us to collect the information again so we can confirm if your current plan is still the better option.

After you complete the form we will send you a permission slip called a “Scope of Appointment.” It will come via email from within a few days. Medicare requires us to send a new one every year for us to give you a recommendation. Please be on the lookout for it.

Once you complete your Scope of Appointment, we will research plans and prepare our recommendation. Our recommendation will also come via email from

From there, you can tell us which plan you’d like and we will process the application for you. You can also schedule a follow-up call with us if you’d like.

Thank you for your partnership with us through this process! We appreciate your trust in us as your agents of choice. 🙂

Note: the info we have on file for you will auto-populate once you enter your email address. If it is out of date or incorrect please enter the correct details.

If you and your spouse are both clients, you can open this link multiple times to submit a form for each of you.

Which type(s) of policies would you like us to research for you?

Please provide your current medications one at a time. Click “Add” below to add multiple medications.

Do you take the brand name or the generic of this medication?

Please provide your current doctors. Click “Add” below to add multiple doctors.

Address where this doctor sees you
Address where this doctor sees you
What is your preferred pharmacy?