Getting Started Medicare Questionnaire

Medicare Getting Started Questionnaire

This information will help us determine your next steps with Medicare
*You are not required to provide any private, protected health information (PHI). The below requested information is for use by Mark E. Werner, MSFS, CFP®, RICP®, ChFC®, CLU®, ChSNC® only to help you make an informed plan decision and will not be shared with any third party. You will be providing the PHI voluntarily and without coercion from Mark E. Werner, MSFS, CFP®, RICP®, ChFC®, CLU®, ChSNC®*

Disclaimer: We do not offer every plan available in your area. Currently we represent 7 organizations which offer 78 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
Your Name - what would you like us to call you?*

First NameLast Name
If your legal name is different than what you usually prefer to be called (perhaps you go by Jim but your legal name is James, or maybe your prefer your middle name), please give us that information too - this is what will be on your Medicare card as well as any applications.

Legal First NameLast Name
Preferred Email*
example@example.com
Do you check your email regularly?*

Yes! EverydayYes! Several times a weekOnly a couple times a monthI rarely check email
Preferred Phone #*

Area CodePhone Number
Do you accept text messages on that phone #?*

YESNOit has that capability, but I prefer not to text
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate:*
Did a friend or family member refer you to us? If so, please let us know who referred you below!
Tell us a little about your situation, please. Things like: Have you been told by your employer that you will needing to sign up for Medicare? If so, when do you lose your employer coverage? Are you retired? Are you looking to compare employer health coverage with Medicare options? Any kind of information like this will be helpful for Mark as he helps you determine your next steps.
Have you received your Medicare Card in the mail yet?*

YES - I have both Parts A and Part BNO- but I signed up and expect it in the mail anydayNO - I haven't applied to Medicare yetYES - but I only have Part A
Medicare Claim # (found on your Medicare Card/ type "N/A" if you don't have yours yet)*
Part A Effective Date (Type "N/A" if you don't have one yet)*
Part B Effective Date (Type "N/A" if you don't have one yet) *
OK, GREAT! Take a deep breath! Perhaps take a screen break by looking out the window for 30 seconds or so... and then let's get some information about your Rx medications (if you have no Rx meds or very few, keep scrolling down to the last section)
Do you use Mail Order?*

I use mail order for ALL of my Rx drugsI use a combination of Brick & Mortar pharmacies + Mail OrderI only use brick & mortar to pick up my Rx drugs
Which Brick & Mortar pharmacy do you prefer? EVEN IF YOU USE MAIL ORDER, please indicate a pharmacy. FOR EXAMPLE: Let's say you needed antibiotics, where would you drive in town to get them? *Please note we cannot search for the lowest priced pharmacy. There are far too many variables and the system doesn't sort that way. Please indicate your preferred brick & mortar pharmacy (please list no more than 2)**
If you're already on a Part D Plan how do you pay for it? If you're not yet, how do you prefer to pay for it going forward?

Auto DeductionI get a monthly billComes out of Social SecurityI'm not sure!
Next, we need a list of your Rx drugs.

We need to know:
- THE NAME OF THE DRUG
- WHETHER IT IS BRAND NAME OR GENERIC (if you don't know, please call your pharmacy. WE won't know that answer, and it can mean the difference of thousands of dollars!)
- THE DOSAGE
- HOW MANY TIMES PER DAY YOU TAKE THIS Rx DRUG (time of day does not matter, we just need to know quantity)
- The MORE you give us that the bottle says, the more we can be sure we match your exact dosage and needs
- You won't necessarily fill out all of these (some of you will fill out none of these because you aren't currently taking any Rx medication), once you've entered in every Rx drug you are currently having filled, scroll to the bottom and hit SUBMIT
- If you are currently prescribed more than 15 Rx drugs, you may include more than 1 in each box.
EXAMPLE:

Rx Drug Name, generic, .5mg, 1 tablet per day

Rx Drug Name, brand, 50mcg, 3 capsules per day

Rd Drug Name, generic, 10mg, the directions are 3x per day, but I only take as needed and take about 5 tablets a month.
Please list Rx Drug 1
Please list Rx Drug 2
Please list Rx Drug 3
Please list Rx Drug 4
Please list Rx Drug 5
Please list Rx Drug 6
Please list Rx Drug 7
Please list Rx Drug 8
Please list Rx Drug 9
Please list Rx Drug 10
Please list Rx Drug 11
Please list Rx Drug 12
Please list Rx Drug 13
Please list Rx Drug 14
Please list Rx Drug 15
OK, you're doing GREAT! Perhaps another screen break? Safety first; maybe a stretch break, too? This is your last step. Let's get your doctor information. If you know for a fact you are NOT interested in Medicare Advantage Plans, you may skip this section and scroll down to the the submit button. If you're not sure which way you're leaning, please go ahead and fill this out so we have the information.
Who is your Primary Care Physician + zip code where your doctor is located?
List any specialists you see. Please include what type of specialist, and the zip code your specialist is located. Example: Dr Kevin Smith, cardiologist, 12345
Which hospital do you prefer? Zip code is helpful here, too!
Are you interested in Dental & Vision options?

YESNOI'm not sure....maybe?
Are you on Medicaid?

YESNOYES, and on a spend down
IF YOU ANSWERED "YES, and on a spend-down", how much $ per month?
Are you on Low Income Subsidy for your prescriptions?

YESNOI'm not sure
Thank you for filling this questionniare out!

Whew, we know that was a lot of work, but it is important and very helpful information to Mark as he helps you determine your next steps and best plans for you and your needs! We will be in touch within the next 3 business days! Keep an eye on your email (unless you told us you don't check it, in which case we'll call the # you specified).

Hit the submit button below.

Please ignore "Jotform" asking if you want to create a questionnaire. That's not US here at Cornerstone Advisors, LLC requesting anything.

You will receive an email confirmation from jotform to the email address you provided above when you submit your questionniare (check your junk, it might be there). If you didn't receive one, check your junk folder, and if you don't hear from us in the next few days, feel free to follow up with us to be sure it got submitted.
Should be Empty:

Medicare Getting Started Questionnaire

OK, GREAT! Take a deep breath! Perhaps take a screen break by looking out the window for 30 seconds or so... and then let's get some information about your Rx medications (if you have no Rx meds or very few, keep scrolling down to the last section)