Medicare Materials Order Form:

Contact Information *First Name: *Last Name: *Address 1: Address 2: *City: *State: *Zip:

Additional Details Email: Select a Directory: Formulary: Evidence of Coverage: Summary of Benefits:

Would you like to receive these items yearly?

Yes, opt me in

No, one-time only

Health Plus Form

Medicare Materials Order Form:

Contact Information *First Name: *Last Name: *Address 1: Address 2: *City: *State: *Zip:

Additional Details Email: Select a Directory: (2025 Directory includes all 2026 providers) Formulary: Evidence of Coverage: Summary of Benefits:

Would you like to receive these items yearly?

Yes, opt me in

No, one-time only