Sandbrook Group Medicare Questionnaire

Sandbrook Medicare Questionnaire
Thank you for taking the time to complete this questionnaire. It is designed to help us find the right Medicare plan for your unique situation. If you are unable to answer any of the questions or do not wish to supply the information at this time, please complete the Contact Information and submit this form to Sandbrook Group. We really look forward to talking to you soon!
Contact Information
Name

First NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
Street Address 1
Street Address 2
City
State
Zip Code
Phone Number*
What County do you live in?
Does a Representative of Sandbrook Group have permission to call or email you?*

YesNo
How do you prefer to meet:*
Which Agent do you wish to meet with?
Medicare Info
Do you currently receive Social Security Benefits?
Are you currently receiving AHCCCS/ Medicaid?
If so, what is your AHCCCS ID Number?
Member ID
Are you currently receiving Medicare?
If so, what is your Medicare ID Number?
Member ID
Effective Date for Part A

MonthDayYear
Date
Effective Date for Part B

MonthDayYear
Date
Gender
Medicare Plans Currently Enrolled In (Check all that apply)

Part ADual Complete/ AHCCCSPart BMedicare SupplementDrug Plan Part DMedicare AdvantageCurrently on an Employer Plan?
Primary Physician Name/ Location
Specialist Physicians Names/ Location
Preferred Pharmacy Name / Location
Current Prescriptions and Dosage

Please list current prescription medications, dosage, and frequency taken. Results are based on the accuracy of the dosage and frequency taken. Actual pricing will be an estimate and is subject to change as Carriers change their formulary and pricing.

	Drug Name	Dosage (mg)/ Type (Tab, Cap, Inj)	Frequency Taken
Rx #1
Rx #2
Rx #3
Rx #4
Rx #5
Rx #6
Rx #7
Rx #8
Rx #9
Rx #10

Please list additional medications and dosages below
Is there anything else you want us to know (or list additional medications)?
How did you hear about us?
Sandbrook Medicare Questionnaire

Sandbrook Medicare Questionnaire
Should be Empty:

Sandbrook Medicare Questionnaire

Contact Information

Medicare Info

Current Prescriptions and Dosage