Medicare Open Enrollment

Waukesha County Residents: Need help comparing 2027 Medicare plans?

Please complete the form below.

Your current and top 2 lowest cost drug and/or advantage plan comparisons will be mailed to you or attend a workshop to receive your plan comparisons.

First Name

Last Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth

Date

Do you have a current drug plan?

Do you have a current Advantage plan?

Name of Advantage plan:

Medicare Part A Start Date:

Date

Medicare Part B Start Date:

Date

Pharmacy Preferences:

Prescription Needs:

Rows	Drug Name	Dose Amount	How often Taken
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How would you prefer to receive your plan comparisons?

What workshop date would you be interested in attending? (Select only ONE option)

I have requested the Elder Benefit Specialist’s (EBS) assistance comparing Medicare Advantage and/or Part D plan options. I understand that the accuracy of the Plan Finder depends upon the information given by the Center for Medicare and Medicaid Services, as well as information I have provided to the EBS Program regarding my medications. The Medicare website is subject to revision and/or error. The most accurate information is available by contacting the plan directly. The EBS is not recommending any particular plan. I take full responsibility for the choice that I make. I understand that it is my responsibility to handle all further matters related to enrollment. If I become aware that my enrollment did not go through, it is my responsibility to follow up with the plan. If I have reason to believe that the enrollment was not successful, I will notify the plan and the EBS immediately. I understand that all enrollments must be made by December 7, 2026. I acknowledge that participants can generally only change plans once per year during the Open Enrollment Period (OEP). By enrolling in this plan now, I understand that, absent a special enrollment period, I may have to wait a year for the next OEP in order to drop or switch plans again. As part of the EBS Program, the EBS Program is required to report and share identifying and other information with the Wisconsin Department of Health Services EBS Program Manager and other relevant state employees for purposes of data reporting and quality assurance. This information also may be shared with funders, such as the Federal Government, as required. Aside from this exception, the EBS Program will not reveal client’s information without the client’s permission unless providing this information for the purpose of accomplishing the client’s goals.

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