Healthcare Provider Information


Start by keeping track of your individual health care coverage needs. Providing correct and complete information regarding your health care providers and prescription drugs will help your Benefits Counselor analyze your health plan coverage specifics.

Please complete and email your health care provider information at least 2-5 days prior to your consultation; doing so will shorten the amount of time you spend on the consultation call. 

  1. Download a copy of the Health care Provider information form
  2. Fill out the form as needed
  3. Save a copy of the completed form, with your health care provider information included, to your computer 
  4. Email the form back to us at Remember, anything you send will be transmitted securely and will never be shared.
  5. Your information will be pre-loaded and available for your Benefits Counselor prior to your consultation

If you would prefer to provide this information by mail, please see your enrollment guide for the necessary form. You will need to make sure you complete and mail your information to arrive at least 10 days prior to your scheduled consultation.

Health Care Provider Information Form

Providing information regarding your health care providers will help your Benefits Counselor.

Click below to download and complete the worksheet. You will need to save a copy of it to your computer before you email it to us; your information will not be automatically saved, so if you close the form before saving your information, it will be lost and you will need to start again.

Download the form