Medicare Consultation Intake Form
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you have a separate mailing address?
No
Yes
Mailing Address (PO Box is allowed)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How Did You Hear About Us?
*
Personal Email
*
example@example.com
Preferred Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do You Currently Have Health Insurance?
*
No
Yes
Current Health Insurance Type
*
Job-based health insurance
Private pay health insurance
Medicare
Name of Employer Providing Your Current Health Insurance
Name of Current Insurance Company
Your health insurance ID number
Date New Medicare Coverage is Needed
*
-
Month
-
Day
Year
Date
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Please Indicate Your Basic Understanding of Medicare
*
I could use a quick refresher on Medicare basics
I have a solid understanding of how Medicare works
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Are You Enrolled in Medicare?
*
No
Yes
Medicare ID Number (if already enrolled in Medicare)
Medicare Part A Effective Date (check your Medicare card)
-
Month
-
Day
Year
Date
Medicare Part B Effective Date (if enrolled - check your Medicare card)
-
Month
-
Day
Year
Date
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Do You Take Prescription Medications Currently?
*
No
Yes
Tell Us About Your Current Prescriptions
Rows
Prescription Name (brand required?)
Dosage(cap/tab)
Monthly Quantity
Refill Frequency
Rx 1
Rx 2
Rx 3
Rx 4
Rx 5
Rx 6
Rx 7
Rx 8
Rx 9
Rx 10
Preferred Retail Pharmacy Name
*
Is Mail-order Pharmacy Option Important to You?
Yes
No
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Do You Have a Primary Care Doctor?
*
No
Yes
Name of Primary Care Doctor
Rows
First Name
Last Name
City/Town
PCP
Do You See Other Specialist Doctors on a Regular Basis?
*
No
Yes
Names of Current Specialist Doctors
Rows
First Name
Last Name
Specialty
City/Town
Specialist 1
Specialist 2
Specialist 3
Specialist 4
Specialist 5
Specialist 6
Specialist 7
Specialist 8
Specialist 9
Specialist 10
Do You Have a Dentist?
*
No
Yes
Dental Providers
Rows
First Name
Last Name
Type
City/Town
Dental 1
Dental 2
Notes or Important Additional Providers (hospitals, rehab facilities, etc.)
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What was your Modified Adjusted Gross Income from 2 years ago?
*
Will your income significantly be reduced this year?
No
Yes
Do you file your taxes individually or jointly with a spouse?
*
Individual Tax Return
Joint Tax Return
Married Filing Individually
Will Your Spouse Need Medicare Coverage?
No
Yes
Name of Spouse
First Name
Last Name
Spouse's Date of Birth
-
Month
-
Day
Year
Date
Is Spouse's Residence the Same as Yours? (for plan option purposes)
No
Yes
Spouse Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is Your Spouse Covered Under Your Health Insurance (or vice versa)?
No
Yes
Your Spouse's Health Insurance Type
Job-based Insurance
Private pay health insurance
Medicare
Name of Employer Providing Your Spouse's Health Insurance
Name of Your Spouse's Health Insurance Company
Spouse's Health Insurance ID Number
Is Your Spouse Enrolled in Medicare?
No
Yes
Spouse's Medicare ID Number
Spouse's Medicare Part A Effective Date (on Medicare Card)
-
Month
-
Day
Year
Date
Spouse's Medicare Part B Effective Date (on Medicare Card)
-
Month
-
Day
Year
Date
Does Your Spouse Take Prescription Medications?
No
Yes
Tell Us About Your Spouse's Current Prescriptions
Rows
Prescription Name (brand required?)
Dosage(Cap/Tab)
Monthly Quantity
Refill Frequency
Rx 1
Rx 2
Rx 3
Rx 4
Rx 5
Rx 6
Rx 7
Rx 8
Rx 9
Rx 10
Spouse's Preferred Retail Pharmacy
Is a Mail-order Pharmacy Important to Your Spouse?
No
Yes
Does Your Spouse have Primary Care Doctor?
No
Yes
Name of Spouse's Primary Care Doctor
Rows
First Name
Last Name
City/Town
PCP
Does Your Spouse See Specialist Doctors on a Regular Basis?
No
Yes
Names of Spouse's Current Specialist Doctors
Rows
First Name
Last Name
Specialty
City/Town
Specialist 1
Specialist 2
Specialist 3
Specialist 4
Specialist 5
Specialist 6
Specialist 7
Specialist 8
Specialist 9
Specialist 10
Does Your Spouse Have Have a Dentist?
No
Yes
Spouse's Dental Providers
Rows
First Name
Last Name
Type
City/Town
Dental 1
Dental 2
Spouse's Notes or Important Additional Providers (hospitals, rehab facilities, etc.)
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What's most important to you?
A plan with low or no medical co-pays
A plan with low monthly premiums
What's most important to you?
A plan with nationwide in-network coverage
A plan with low monthly premiums
*NOTE: Emergency room coverage is available worldwide on all plans.
What's most important to you?
A plan that includes dental, vision and health club benefits
A plan with low or no medical co-pays
Do you know what type of Medicare plan you are interested in?
Medicare Advantage (Part C) that includes Part D
Medicare Supplement ("MediGap") + Part D
I do not know yet
Please check off the insurance companies that you may prefer working with:
Aetna
AARP/UnitedHealthcare
Blue Cross Blue Shield
Cigna
Humana
Wellcare
Other
No preference
Submit
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