Essential Solutions

Essential Solutions Discovery Form

Complete, sign and collect the Essential Discovery.

Last Name

Middle Name

First Name

Date of Birth

Phone

Street Address

City

State

Zip

Country

Email

Current Plan

Current Plan Description

New Plan

New Plan Description

Primary Care

Phone

Name

PCP ID

Medicare ID

Medicaid

Hospital - Part A

LIS Status

SEP

Doctor - Part B

Specialist

Phone

Add a pharmacy option?

Load an existing discovery wet form

No	Rx	Tier	Co Pay
1

"We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."

"Calls may be monitored or recorded for quality assurance and training purposes." In order to comply with CMS guidelines.

optout - If you would like to opt out from recorded phone calls, you may choose to do so by checking the opt out box and signing below.

"By signing this form, you agree that an authorized representative or licensed insurance advisor may contact you by phone, e-mail or mail to answer your questions and provide additional information about Medicare Advantage, Part D or Medicare Supplement Insurance plans. This is a solicitation for insurance."

Signature of applicant

Date