Medicare Intake Form
First Name
*
Last Name
*
Date of birth
*
Zip Code
*
Email
*
Phone
*
County
Medicare Number
Part A Effective
Part B Effective
Do you have Medicare Part D?
Do you qualify for assistance?
Do you have any other forms of insurance?
QI-1 / SLMB / QMB
LIS
CHRONIC
SPECIFIC PLAN MEDICAID #
Do you have a Primary Care Physician (PCP)?
Name of Primary Care Physician (PCP)?
How many different prescriptions are you taking?
Would you be willing to switch from a name brand to a generic for a lower out-of-pocket cost?
Name of Prescriptions
Are dental benefits an important factor in your next health plan?
Do you have a dentist that you visit regularly?
Name of other Doctors, Hospitals, Dentists, Pharmacies
Are fitness memberships and healthy lifestyle benefits important to you?
Are vision benefits an important factor for you?
Are hearing benefits an important factor in your next health plan?
Are you interested in any of these other benefits?
Do you have a Power of Attorney? If so, who?
Do you currently use any tobacco products?
What are the things you like about your current plan?
If there were some things, you could change with your current plan what would they be?
Source of business
Date of appointment
SOA dated at least 48hrs in advance. If “no” reason?
Products discussed
If other health related products, list them here
Names of who was in attendance
Identification Documents
Other Documents
Name of Agent Requesting Quote
*
Email of Agent Requesting Quote. Quotes will be sent to this email
*
SUBMIT