Resources

Downloadable Client Forms & Resources

Access official administrative paperwork, carrier forms, and appeal requests. Download, print, or complete these documents to submit them directly to your agent or provider.

Medicare & Federal Administration Forms

Late Enrollment Penalty (LEP) Reconsideration Request Form

Official appeal document used to dispute or lower a Part D Late Enrollment Penalty assessed by Medicare.

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Part B Request for Employer Information (CMS-L564)

Used to verify past employment-based health coverage so you can enroll in Medicare Part B past age 65 without incurring a penalty.

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Medicare Part B Electronic Funds Transfer (EFT) Form (CMS-588)

Authorizes automatic monthly bank transfers to cover Medicare Part B premium payments.

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1-800-MEDICARE Authorization / Power of Attorney Form (CMS-10106)

Authorizes Medicare to share your private health information with a designated representative, family member, or broker.

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Prescription Drug & Appeal Documents

Drug Reconsideration & Exception Request Form

Used to request coverage for a prescription medication not currently on your plan's formulary, or to apply for a lower copay tier.

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Client Intake & Health Forms

Pre-Underwriting Health Questionnaire

Preliminary health history evaluation form used by agents to determine eligibility for Medicare Supplement (Medigap) plans requiring medical underwriting.

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Claims & Carrier Documents

ADA Dental Claim & Out-of-Network Dental Claim Forms

Standard reimbursement submission form for out-of-network dental care and procedures.

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General Out-of-Network Medical Claim Form

Form submitted directly to the insurance carrier for direct out-of-pocket medical expense reimbursements.

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UnitedHealthcare (UHC) Member Forms & Resources

Direct access to UnitedHealthcare's member forms portal for enrollment verification, automatic payments, claims, and policy modification documents.

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How to Submit Completed Forms

Download and print the required document.

Complete all highlighted fields and sign where indicated.

Email your completed form to [email protected] or mail it to 8821 Manchester Rd., Brentwood, MO 63144.

Need assistance filling out a form? Call us directly at (855) 640-8060 to speak with a licensed representative.

(855) 640-8060 [email protected]

8821 Manchester Rd., Brentwood, MO 63144