Chris A Roth

Medicare & Medicare Advantage Plan Assessment

Share a few details about your situation so we can review your Medicare options, compare plans, and help you choose coverage that fits your doctors, prescriptions, and budget.

Step 1: Basics

Step 2: Medicare & Prescriptions

Step 3: Priorities & Consent

First Name *

Last Name *

Date Of Birth

Phone *

State

Email *

What best describes your current Medicare status?

When did (or will) you first become eligible for Medicare?

Do you have a list of current prescriptions?

What matters most to you when choosing a Medicare plan?

How comfortable are you with your current Medicare coverage?

Approximate Monthly Budget for Medicare-Related Premiums

Do you have specific doctors, clinics, or hospitals you want to keep?

Anything specific you’d like me to know or compare?

Best Time to Reach You

Consent to be contacted *

By checking this box and clicking “Submit My Medicare Plan Assessment”, you agree that Chris A. Roth and/or our partner carriers may contact you at the phone number and email address provided (including by autodialed, prerecorded, or artificial voice calls and text/SMS messages) about Medicare, life insurance, and related products. You understand that your consent is not a condition of purchase and that you may revoke consent at any time. Message and data rates may apply. Your information is confidential and will only be used to provide your personalized recommendations.

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